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I 


OXFORD  MEDICAL 
PUBLICATIONS 


With  the  Compliments  of  the 

Joint  War  Committee  of  the  'British 

T^d  Cross  Society  gf  the  Order  of 

St.  John  of  Jerusalem  in  England 

83   Vail  Mall,  London,  S.ff.t. 


PLASTIC  SURGERY  OF  THE  FACE 


PUBLISHED   BY  THE   JOINT    COMMITTEE   OF 

HENRY     FROWDE,     HODDER    AND    STOUGHTON 

17   WARWICK   SQUARE,   LONDON,    E.C-4 


PLASTIC  SURGERY 
OF  THE  FACE 

BASED  ON  SELECTED   CASES  OF 

WAR   INJURIES   OF   THE   FACE 

INCLUDING   BURNS 

WITH  ORIGINAL   ILLUSTRATIONS 

«Y 

H.    D.    GILLIES,  C.B.E.,  F.R.G.S. 

MAJOR   R.A.M.G. 

SURGICAL    SPECIALIST    TO    THE    QUEEN'S    HOSPITAL,    S1DCUP 

SURGEON    IN    CHARGE    OK    THE    DEPARTMENT    FOR    PLASTIC    SURGERY,    AND    LATE    SURGEON    IN    CHARGE 

OF    THE    EAR,    NOSE,    AND    THROAT    DEPARTMENT,    PRINCE    OF    WALEs's    HOSPITAL,    TOTTENHAM 

I.ATE    CHIEF    CLINICAL    ASSISTANT,    THROAT    DEPARTMENT,    ST.     BARTHOLOMEW'S    HOSPITAL 

HON.    FELLOW    NATIONAL   DENTAL   SOCIETY    OF   AMERICA 


WITH   CHAPTER   ON 

THE  PROSTHETIC  PROBLEMS  OF  PLASTIC  SURGERY 

BY 

GAPT.   W.   KELSEY   FRY,    M.C.,    R.A.M.C. 

SENIOR    DENTAL    SURGEON,    QUEEN'S    HOSPITAL,    SIDCCP ;    SENIOR   DEMONSTRATOR    AND    DENTAL 
OFFICER  IN  CHARGE  OF   THE    1'KOSTHETIC  AND  METALLURGICAL  DEPARTMENT,  GUY'S  HOSPITAL 

AND 

REMARKS  ON  ANESTHESIA 

BY 

CAPT.   R.  WADE,   R.A.M.C. 

LATE  SENIOR  ANAESTHETIST,  QUEEN'S  HOSPITAL  ;  ASSISTANT  ANAESTHETIST,  ST. 
BARTHOLOMEW'S  HOSPITAL  ;  ANAESTHETIST,  GREAT  NORTHERN  CENTRAL  HOSPITAL 


LONDON 
HENRY   FllOWDE  HODDER   AND    STOUGHTON 

OXFORD  UNIVERSITY  PRESS  WARWICK  SQUARE,  E.C. 

1920 


PRINTED   IX  OREAT  BRITAIN 

nv  HA7.ru.,  WATSON  AND  TINEY,  LT>., 

LONDON    AND    AYLESIH'HY'. 


DEDICATED 
I!Y    SPECIAL    PERMISSION    TO 

HER   MAJESTY  QUEEN    MARY 

WHOSE  NEVER-FAILING  INTEREST  AND  BENEFICENT 
INFLUENCE  HAVE  BEEN  A  PERPETUAL  SOURCE  OF  HELP 
AND  ENCOURAGEMENT  TO  PATIENT,  DOCTOR,  AND  NURSE 


INTRODUCTION 

I  HAVE  had  the  pleasure  of  watching  Major  Gillies's  plastic  work  since  its  initiation 
at  the  Cambridge  Hospital  at  Aldershot,  and  later  at  the  Queen's  Hospital 
at  Sidcup,  where  he  and  his  British  colleagues  competed  so  cordially  and  so 
successfully  with  the  surgeons  from  the  Dominions  in  their  efforts  to  restore 
the  disfigured  faces  of  the  wounded  to  their  normal  form. 

It  was  largely  due  to  him  that  such  rapid  progress  was  effected  in  this 
special  and  difficult  form  of  surgery,  of  which  little  or  nothing  was  known  before 
the  war.  Methods  were  employed  and  scrapped  with  great  rapidity  as  im- 
provements were  devised. 

It  would  be  difficult  to  exaggerate  the  excellence  of  the  work  that  was 
done  by  the  several  surgeons.  Advantage  was  taken  of  it  by  many  Americans 
and  others,  who  profited  greatly  from  observing  the  methods  of  treatment 
that  had  been  developed  there. 

This  book,  which  is  so  handsomely  illustrated,  gives  a  very  thorough  account 
of  the  many  novel  procedures  which  have  been  devised  or  elaborated  at  the 
Queen's  Hospital.  It  will  afford  an  excellent  basis  for  much  civil  work,  and 
I  trust  that  special  departments  for  plastic  surgery  will  be  started  at  the  several 
teaching  hospitals,  and  that  means  will  be  taken  to  secure  the  services  of  those 
surgeons  who  have  had  such  wonderful  opportunities  to  perfect  themselves 
in  this  special  work.  It  is  not  sufficiently  recognised  how  readily  the  skill  de- 
veloped in  this  branch  of  war  surgery  is  directly  applicable  to  the  relief  of  dis- 
figurements met  with  in  civil  life.  Ugly  scars  resulting  from  burns  and  accidents, 
deformities  of  the  nose  and  lips,  hare  lip  and  cleft  palate,  abnormal  protrusion 
or  ill  development  of  the  mandible,  moles,  port- wine  stains,  all  abound,  and  are 
not  only  the  constant  source  of  the  greatest  distress  and  anguish,  but  materially 
lower  the  market  value  of  the  individual.  There  is  also  a  vast  field  in  the  oblitera- 
tion of  marks  of  operative  interference,  such  as  removal  of  malignant  growths. 

This  book,  written  by  so  skilled  and  experienced  an  operator  as  Major 
Gillies,  is  invaluable  to  every  general  surgeon  as  well  as  to  the  plastic  specialist. 

I  would  also  like  to  congratulate  the  publishers  on  the  excellent  manner 
in  which  they  have  produced  this  volume. 

W.  ARBUTHNOT  LANE. 

September  1919. 

vii 


PEEFACE 

PLASTIC  Surgery  of  the  Face  is  not  a  new  development.  Surgeons  of  all  civilised 
and  some  uncivilised  countries  have  from  time  to  time  evolved  methods  of 
repair  for  various  disfigurements. 

But  not  until  the  organisation  of  the  new  home  Medical  Service  necessitated 
by  the  late  war,  with  the  need  for  refinement  in  the  matter  of  segregation  of 
cases  in  special  hospitals  so  ably  met  by  Lieut.-General  Sir  Alfred  Keogh,  our 
late  Director-General,  has  there  been  opportunity  for  anything  but  disjointed 
study  in  this  department  of  surgery. 

In  the  later  development  of  the  work,  the  continuity  of  research  was  main- 
tained by  facilities  afforded  by  his  successor,  Sir  John  Goodwin,  for  the  retention 
of  the  specially  trained  staff,  in  spite  of  the  difficulties  caused  by  the  growing 
shortage  of  medical  officers. 

The  author  wishes  to  place  on  record  his  thanks  to  Major-Generals  Sir 
Anthony  Bowlby  and  Sir  George  Makins,  and  Sir  Frank  Colyer,  who,  in  their 
capacity  as  consultants,  laid  before  the  Director-General  the  importance  of 
organising  means  for  the  intensive  study  of  this  special  branch  of  reparative 
surgery. 

The  work  on  which  this  book  is  founded  began  in  January  1916,  at  the 
Cambridge  Hospital,  Aldershot,  where,  under  the  stimulus  and  able  direction 
of  Colonel  Sir  W.  Arbuthnot  Lane,  the  treatment  of  war  injuries  of  the  face 
and  jaw  was  studied  under  suitable  conditions  in  wards  earmarked  for  the 
purpose. 

The  author  had  the  advantage  there  of  co-operating  with  Captain  L.  A.  B. 
King,  L.D.S.,  attached  R.A.M.C.,  whose  help  as  Chief  Dental  Surgeon  through 
that  stern  period  of  doubt,  trial,  and  error  was  invaluable.  The  influence  of 
his  work  is  still  evident  in  our  treatment  of  jaw  injuries  to-day. 

A  rapid  increase  in  the  scope  of  the  work  led  to  the  removal  of  the  hospital 
to  Sidcup,  where,  thanks  to  the  sympathy  and  energy  of  Colonel  Sir  William 
Arbuthnot  Lane,  Lieut. -Colonel  J.  11.  Colvin,  and  Major  Waldron,  C.A.M-C., 


Plastic  Surgery  of  the  Face 
by  H.D.   Gillies,  Oxford, 
University  Press,   1920. 

x  PREFACE 

it  was  placed  on  an  Imperial  basis.  The  collection  of  the  cases  of  facial  injuries 
from  the  British,  Canadian,  Australian,  and  New  Zealand  forces  in  one  hospital 
under  their  own  medical  officers  has  proved  a  factor  of  prime  importance  in 
the  improvement  of  methods  of  treatment. 

Major  Waldron  and  Captain  Risdon  (Canadian  Section),  Colonel  Xewland, 
D.S.O.  (Australian  Section),  and  Major  Pickeril,  O.B.E.  (New  Zealand  Section), 
and  the  officers  serving  with  them,  joined  heartily  in  friendly  rivalry  and  healthy 
competition,  to  the  great  benefit  of  these  poor  mutiles. 

Further,  with  the  arrival  of  American  surgeons  in  1918  under  Colonel  Vilray 
P.  Blair,  M.R.C.U.S.A.,  our  wounded  had  call  upon  surgical,  skill  from  the 
whole  Anglo-Saxon  race.  Each  surgeon  had  the  assistance  of  one  or  more 
colleagues  from  the  New  World,  to  their  mutual  advantage. 

NYcdless  to  say,  the  author  realises  his  indebtedness  to  the  numerous  visiting 
and  consulting  surgeons  who  from  time  to  time  have  encouraged  him  by  their 
advice. 

The  knowledge  of  their  interest  and  good-will  has  been  a  most  powerful 
stimulus  towards  perseverance  in  times  when  difficulties  appeared  insurmount- 
able. He  wishes  particularly  to  thank  Sir  W.  Arbuthnot  Lane,  Sir  Francis 
Farmer,  and  Sir  Frank  Colyer,  among  consultants ;  and,  among  his  British 
colleagues,  Major  G.  C.  Chubb,  Captains  C.  F.  Rumsey,  the  late  E.  G.  Robertson, 
F.  E.  Sprawson,  J.  L.  Aymard,  R.  Montgomery,  H.  C.  Malleson,  and  A.  L.  Fraser 
in  the  earlier  part  of  the  work,  and  later  Captain  T.  P.  Kilner,  T.  Jackson,  and 
Majors  H.  Bedford  Russell  and  J.  J.  M.  Shaw,  M.C. 

In  particular,  the  stimulus  of  co-operation  with  Major  Seccombe  Hett  has 
considerably  advanced  the  treatment  of  injuries  to  the  nose ;  while  the  pioneer 
work  of  Captain  King  on  the  jaw  has  been  maintained  and  further  developed 
by  Captain  W.  Kelsey  Fry,  M.C.,  R.A.M.C.,  Chief  Dental  Surgeon,  who  has 
written  a  chapter  on  the  use  of  Prostheses  in  this  work.  In  this  connection  the 
work  of  Valadier  and  Kasanjian  in  France  has  been  of  great  service  in  the 
improvement  of  the  treatment  of  jaw  wounds.  I  am  indebted  to  the  former 
for  many  photographs  of  the  original  conditions,  and  to  both  for  the  stimula- 
tion of  their  work  and  for  much  kindly  encouragement. 

Among  many  American  colleagues  Captain  Ferris  Smith  has  shown  himself 
the  most  constructive  critic  the  author  has  had  the  pleasure  of  knowing.  He 
was  of  great  assistance  in  the  preparation  of  the  early  proofs  of  this  work. 

Not  a  small  feature  in  the  development  of  this  work  is  the  compila- 
tion of  case  records.  The  foundation  of  the  graphic  method  of  recording 
these  cases  lies  to  the  credit  of  Professor  H.  Tonks  (Slade  Professor),  many 
of  whose  diagrams  and  photographs  of  his  remarkable  pastel  drawings  adorn 
these  pages. 


PREFACE  xi 

Unfortunately,  his  other  duties  forbade  his  taking  as  large  a  part  in  the 
work  as  he  and  we  ourselves  could  have  wished.  Latterly,  his  work  has 
been  ably  carried  on  by  Mr.  Sidney  Hornswick,  who,  on  his  own  initiative, 
has  considerably  improved  and  standardised  methods  of  recording  flap 
operations. 

The  compilation  of  notes  in  the  early  part  of  our  work  was  carried  on 
voluntarily  by  Mr.  Thomas  Pope.  The  author  cannot  sufficiently  thank  him 
for  the  sterling  value  of  his  work  and  the  loyalty  with  which  he  persevered 
at  his  self-appointed  task  through  two  full  and  difficult  years. 

Lieutenant  J.  Edwards  has  not  only  been  responsible  for  the  preparation 
of  routine  plaster-cast  records,  but  for  a  very  important  part  of  our  work, 
the  reconstruction  of  features  on  the  casts  as  a  preliminary  to  surgical 
reconstruction. 

Herein,  guided  by  the  surgeon  in  the  matter  of  surgical  possibilities,  he 
strives,  sometimes  for  the  ideal,  more  often  for  the  best  possible  surgical  com- 
promise ;  and  his  work  calls  for  constructive  imagination  of  a  very  high 
order.  Where  chances  of  surgical  repair  are  not  evident  he  co-operates  with 
Captain  Fry  in  the  provision  of  as  perfect  a  mechanical  restoration  as 
possible. 

In  the  X-ray  Department  Captain  H.  Mulrea  Johnston  has  displayed  great 
ingenuity  and  resource  in  evolving  standard  positions  for  radiographic 
records,  particularly  of  jaw  injuries.  Latterly,  his  place  has  been  ably  taken 
by  Captain  R.  A.  C.  Rigby. 

The  majority  of  the  photographic  figures  in  the  book  have  been  prepared 
by  Mr.  Sidney  Walbridge.  Their  excellence  speaks  for  itself,  but  gives  no 
idea  of  the  time  and  care  this  late  N.C.O.  has  devoted  to  ensuring  that  they 
shall  be  an  honest  and  true  record.  He  has  had  to  suborn  his  art  to  this  end, 
sternly  suppressing  the  temptation  to  manipulate  the  lighting  or  retouch  the 
negatives. 

The  work  of  correcting  later  proofs  has  been  kindly  undertaken  by  my 
colleague,  Mr.  H.  Bedford  Russell.  The  heavy  secretarial  work  has  been  chiefly 
performed  by  the  author's  patients  (for  the  most  part  E.  J.  Greenaway  ;  partly 
also  R.  W.  D.  Seymour),  who  have  stuck  to  their  task  with  persistent,  cheerful 
loyalty,  in  the  intervals  between  their  operations. 

The  author  takes  this  opportunity  of  thanking  his  publishers  for  their  oft- 
tried  leniency  in  regard  to  delays  in  the  production  of  "  copy."  In  extenuation, 
he  would  plead  a  strong  penchant  for  laying  aside  the  pen  in  favour  of  the 
scalpel  whenever  a  plastic  problem  presented  itself. 

Above  all,  the  author  cannot  adequately  express  what  he  owes  to  the  loyal 
co-operation  and  assistance  of  the  medical  officers — surgeons,  physicians,  and 


xii  PREFACE 

ana-sthetists  alike — and  the  Matron,  and  the  theatre-  and  ward-nursing  staffs 
of  this  hospital,  whose  shoulders  have  borne  the  brunt  of  the  work.  Assiduous 
and  intelligent  care  in  the  after-treatment  of  these  eases  is  a  prime  necessity, 
and  calls  for  the  highest  standard  of  watchful  skill. 

Finally,  the  author  wishes  to  thank  Lieut. -Colonel  J.  R.  Colvin,  Com- 
mandant of  the  Queen's  Hospital,  for  his  unfailing  help  and  fairness  of  treatment 
throughout  two  long  years.  His  powers  of  organisation  and  ready  grasp  of 
the  situation  have  alone  rendered  possible  the  continuity  of  the  work  in  times 
of  stress. 

H.  D.  G. 

February  1920. 


CONTENTS 


CHAPTER    I 


PAGE 


PRINCIPLES  :    HISTORICAL    .........         3 

CHAPTER    II 

REPAIR  OF  THE  CHEEK         .          .         .          .          .          .          .          .          .37 

CHAPTER    III 

INJURIES  OF  THE  UPPER  LIP        ........       77 

CHAPTER    IV 

INJURIES  OF  THE  LOWER  LIP  AND  CHIN       ......     123 

CHAPTER    V 

PROSTHETIC  APPLIANCES  IN  RELATION  TO  PLASTIC  SURGERY  .          .     193 

CHAPTER    VI 

INJURIES  OF  THE  NOSE        .......  .211 

CHAPTER    VII 

INJURIES  IN  THE  REGION  OF  THE  EYES,  INCLUDING  BURNS  OF  THE  FACE     300 
INJURIES  TO  THE  PINNA      .........     381 

CHAPTER    VIII 

PLASTIC  SURGERY  IN  CIVIL  CASES 391 

INDEX  401 


PRINCIPLES 


CHAPTER    I 
HISTORICAL 

THE  origin  of  plastic  surgery  is  of  the  greatest  antiquity.  From  time 
i mmemorial  rhinoplasty  has  been  performed  in  India  for  the  relief  of  the  dis- 
figurement caused  by  punitive  mutilation  of  the  nose.  Two  methods  appear 
to  have  been  employed,  though  the  forehead-flap  is  the  only  one  the  use  of 
which  has  survived  in  India  to  this  day. 

A  method  embodying  the  use  of  cheek-flaps  is  described  in  the  Ayurveda, 
the  sacred  medical  record  of  the  Hindoos,  but  it  has  had  to  yield  to  the  forehead- 
flap  method — a  striking  parallel  to  what  has  occurred  in  Europe  in  the  last 
few  centuries.  The  French  (or  German)  cheek-flap  method  has  been  relegated 
to  the  lumber-room  of  surgery,  and  a  development  of  the  Indian  method,  which 
includes  the  important  improvements  evolved  by  Keegan  and  Smith,  has  pride 
of  place  Jx^djiy. 

In  perusing  the  literature  of  this  subject,  one  is  struck  chiefly  with  the 
lack  of  appreciation  of  the  need  for  a  lining  membrane  for  all  mucous-lined 
cavities.  Not  until  Keegan's  time  was  it  given  any  prominence,  and  perhaps 
even  he  did  not  appraise  it  at  its  true  value.  And  so  it  is  that  the  various 
classical  methods  take  their  name  from  the  covering  flap  employed.  In  actual 
fact,  except  that  forehead  skin  most  closely  resembles  nose  skin,  the  origin  of  the 
covering  is  the  least  important  part. 

The  Italian  method,  which  originated  apparently  in  Sicily  about  1415 
and  was  developed  by  Tagliacozzi  in  Italy  forty  years  later,  consists  in  the 
transference  of  skin  for  a  nose-covering  from  the  patient's  own  arm,  in  two 
stages,  the  patient  being  immured  in  a  fixation  apparatus  while  the  flap  takes. 
This  method  was  feasible  in  those  stern  times,  but  the  more  than  irksome  fixation 
is  not  tolerated  by  the  modern  patient,  and  it  has  been  discarded.  The  principle 
on  which  it  is  based,  however,  is  of  wide  application,  and  a  modification  of  it, 
the  author's  tube-pedicle  method,  is  in  routine  use  for  some  of  our  operations. 

As  in  rhinoplasty,  so  in  the  rest  of  present-day  plastic  work,  the  principles 
laid  down  by  the  fathers  of  surgery  are  found  still  to  be  of  general  application. 
There  is  hardly  an  operation — hardly  a  single  flap— in  use  to-day  that  has 
not  been  suggested  a  hundred  years  ago.  But  our  work  is  original  in  that  all 


4  PLASTIC    SURGERY 

of  it  has  had  to  be  built  up  again  de  novo.     It  does  not  fall  to  the  lot  of  every 
surgeon  to  see  even  one  chciloplasty  in  his  training. 

The  earlier  months,  then,  were  spent  in  a  very  thorough  trial  of  the  then 
known  methods.  It  has  been  illuminating  to  discover  the  impracticability 
of  many  of  these,  which  would  appear  to  have  been  put  forward  on  the  study 
of  one  case  only,  or  even  on  purely  theoretical  grounds.  Among  the  sponsors 
of  really  practicable  methods  the  names  of  Tagliacozzi,  Nelaton,  Keegan,  and 
Smith  stand  out  prominently. 

PRINCIPLES 

It  is  the  author's  aim  here  to  discuss  principles  in  the  order  of  their  ap- 
plication in  a  given  case.  They  will  thus  be  dealt  with,  in  the  following  order : 

HISTORY,  ETC.  ANESTHESIA. 

EXAMINATION.  OPERATION. 
EARLY  TREATMENT.  General  Technique. 

PLANNING  THE  REPAIR.  Stages. 

1.  Lining  Membrane.  Suture. 

2.  Contour  and  Supports.  Dressings. 

3.  Covering  Tissues.  After  Treatment. 

HISTORY,  ETC. 

The  history  of  the  injury  is  obtained,  together  with  any  existing  record 
of  the  early  condition,  and  if  possible  of  the  condition  prior  to  injury.  It  is 
of  importance  also  to  obtain  information  as  to  the  presence  of  luctic  or  tuber- 
cular taint,  and  as  to  the  patient's  healing  powers  as  shown  in  former  operations. 

EXAMINATION 

The  majority  of  failures  in  plastic  surgery  are  due  to  errors  the  commission 
of  which  would  lead  to  failure  in  any  form  of  surgery.  Thus,  mistakes  in  diagnosis 
due  to  inadequate  examination  are  perhaps  the  commonest  cause  of  indifferent 
treatment.  This  element  of  difficulty  in  diagnosis  may  not  at  first  sight  be 
obvious.  The  word  diagnosis  in  this  work  is  used  in  its  literal  sense,  namely, 
to  mean  a  thorough  knowledge  of  the  condition  present — i.e.  the  exact  loss  in 
terms  of  anatomical  structure. 

The  routine  examination  of  our  cases,  with  preparation  of  records  of  the 
condition  on  admission,  occupies  nearly  a  week  ;  but  the  time  so  lost  is  regained 
a  hundredfold.  The  examination  merely  of  the  surface  of.  the  lesion,  simple  as 


PRINCIPLES  5 

it  would  sound,  is  fraught  with  dangerous  pitfalls.  One  has  seen  a  case  in 
which  a  point  a  quarter  of  an  inch  above  the  angle  of  the  mouth  really  belonged 
to  the  infra-orbital  margin.  The  tissues  had  been  stretched  to  this  extent 
without  dragging  down  the  lower  lid  to  any  marked  degree,  and  one  might 
have  been  forgiven  for  regarding  the  stretched  skin  as  part  of  the  cheek. 

Here,  as  elsewhere,  the  aim  is  to  estimate  first  the  amount  of  loss  ;  and, 
secondly,  the  possibility  of  correcting  displacement. 

It  is  often  impossible  to  do  so  till  one  has  undone  some  previous  effort  at 
repair. 

A  moment's  consideration  will  show  that  no  estimation  of  the  loss  or  dis- 
tortion of  soft  tissues  can  be  of  use  unless  coupled  with  a  knowledge  of  the 
condition  of  the  bony  tissue.  When  there  is  greater  loss  of  the  underlying 
mandible  than  of  the  skin,  one  is  apt  to  conclude  that  there  is  no  great  loss 
of  skin.  In  such  a  case,  one  must  visualise  a  completely  restored  mandible, 
and  then  judge  whether  the  remaining  soft  tissues  are  sufficient  to  cover  it. 
In  this  connection,  if  a  photograph  is  obtainable  of  the  condition  before  injury 
it  will  often  be  of  great  assistance.  In  the  case  of  any  organ  forming  the  wall 
of  a  mucous  cavity,  such  as  the  lip,  it  is  necessary  to  make  an  accurate  estimate 
of  the  loss  of  mucous  membrane.  In  fact,  estimation  of  loss  should  be  made 
separately  in  regard  to  (1)  the  mucous  lining,  (2)-  the  bony  or  cartilaginous 
support,  and  (3)  the  skin  covering.  The  estimation  of  bony  loss  necessitates 
intranasal  and  intra-oral  and  radiographic  examination  in  addition  to  surface 
palpation,  and  even  then  is  often  difficult  to  make  in  cases  where  the  injury 
is  symmetrical.  One  has  seen  an  intrinsically  well-made  nose  constructed  upon 
a  bed  at  least  one  inch  posterior  to  the  normal  plane  :  the  loss  of  the  nasal  spine 
and  premaxilla  had  not  been  taken  into  consideration,  and  the  face,  to  the 
surgeon's  disappointment,  presented  an  undershot  appearance. 

To  overcome  such  difficulties,  Surgery  calls  Art  to  its  aid.  A^  pi  aster  cast 
of  the  face  is  made,  and  thereon  the  sculptor,  aided  by  early  photographs  if 
available,  models  the  missing  contours.  With  radiographs  to  confirm  that  the 
apparent  loss  is  not  merely  displacement,  the  surgeon  now  has  data  for  adequate 
diagnosis. 

EARLY  TREATMENT 

The  diagnosis  established  and  recorded,  the  surgeon  plans  his  repair.  The 
first  principle  is  one  which  the  author  believes  to  govern  the  whole  treatment 
of  facial  injuries,  and  this  is  that  all  jiormal  jjssue_shmild  be  replaced  as  early 
asjjossible,  and  maintained  in  its  normal  position.  In  treating  an  early  wound 
there  is  a  natural  disposition  to  try  to  close  unsightly  gaps.  More  harm  than 


6  PLASTIC    SURGERY 

good  is  done  thereby,  as  the  reactionary  swelling  and  the  frequent  suppuration 
cause  more  scar  tissue  than  would  otherwise  have  to  be  dealt  with,  and  the 
stitches  only  too  often  give  way.  In  addition  to  this  undue  stretching  of  the 
damaged  tissues,  the  early  cutting  of  flaps  is,  in  the  author's  opinion,  to  be 
condemned ;  for,  even  when  this  procedure  is  successful,  no  obvious  gain  in  time 
or  appearance  is  obtained,  while  considerable  risk  of  suppuration  is  run.  It 
follows,  therefore,  that  split  lips,  lacerated  noses,  and  gashed  cheeks,  where 
the  loss  of  tissue  is  negligible,  should  be  carefully  sewn  up  with  drainage  as 
soon  as  possible.  Every  effort  should  be  made  to  replace  tissues  in  their  normal 
position  by  stitches,  strapping,  head-gear  apparatus,  nasal  supports  and  splints, 
but  never  into  abnormal  positions.  There  is  one  exception  to  this  which  de- 
serves mention,  namely,  that  tags  of  mucous  membrane  should,  faute  de  mieux, 
be  delicately  attached  to  any  neighbouring  raw  surface  to  preserve  their  form 
and  vitality. 

In  the  very  common  facial  injury,  where  one  of  the  mucous  cavities  is 
involved  in  the  wound  and  the  loss  is  so  great  that  the  repair  cannot  be  done 
without  undue  stretching,  the  modern  practice  of  excising  the  wound  should 
be  brought  into  play,  and  then  the  skin  sewn  to  mucous  membrane  round  the 
margin  of  the  defect.  This  should  be  done  wherever  possible,  so  that  as  little 
raw  area  as  possible  is  left  to  granulate.  In  dealing  with  lacerated  mucous 
membrane,  the  greatest  delicacy  of  touch  must  be  used,  and  in  effecting  the 
suture  as  little  manipulation  of  the  tissues  as  possible  should  be  indulged  in. 
A  corollary  of  this  belief  of  the  author's  is  that  in  clearly  defined  gaps  of  the 
mandible,  the  end  of  the  bone  should  be  smoothed  off  and  the  buccal  mucous 
membrane  sewn  across  the  raw  bone,  a  procedure  advocated  by  Trotter.  Were 
it  possible  of  achievement  as  a  routine,  it  would  almost  certainly  prevent  ci- 
catricial  approximation  of  the  fragments ;  but  one  realises  that,  with  many 
other  suggestions  for  early  treatment,  it  is  a  counsel  of  perfection,  and,  in  very 
severe  injuries,  may  well  be  impracticable  under  conditions  of  active  warfare. 

In  the  early  treatment  of  all  wounds  involving  the  oral  cavity  the  dental 
surgeon  must  be  encouraged  to  take  a  large  share  of  responsibility.  His  treat- 
ment will  begin  naturally  with  a  general  nettoyage  of  the  alveolar  area.  Loose 
and  septic  teeth  and  stumps  must  be  extracted,  and,  as  soon  as  can  be  accurately 
determined,  the  teeth  obviously  in  the  line  of  fracture  (the  persistence  of  which 
is  not  of  vital  importance  for  the  fixation  of  the  fragments)  should  be  removed. 
Frequently  the  decision  as  to  whether  a  tooth  is  or  is  not  in  the  line  of  fracture 
has  to  be  modified,  and  it  may  become  necessary  to  remove  more  teeth  than 
was  first  expected.  The  most  careful  watch  for  persistent  pockets  of  pus  must 
be  maintained. 

In  many  cases  it  will  be  found  of  great  advantage  to  provide  infra-mandibular 


PRINCIPLES  7 

drainage  on  to  the  neck  surface  beneath  the  various  lines  of  fracture.  This 
sounds  reasonable  and  simple,  but  in  practice  it  is  found  quite  difficult  adequately 
to  drain  some  classes  of  comminuted  fractures,  and  the  mandibular  remains 
are  apt  to  carry  on  their  existence  in  a  sump  of  pus  (visually,  one  must  admit, 
with  considerable  success  !). 

For  this  as  well  as  for  general  reasons,  the  passive  drainage  is  greatly  assisted 
by  frequent  forcible  irrigation,  the  Carrel  continuous  irrigation  being  not  always 
practicable  in  this  region. 

By  adequate  drainage  alone  are  the  dangers  of  secondary  haemorrhage 
avoided,  and  it  is  one's  experience  that  those  cases  in  which  there  is  a  small 
perforating  wound  of  the  body  of  the  mandible  are  most  prone  to  this  disaster. 
One  has  never  seen  a  serious  haemorrhage  in  a  case  of  facial  wound  in  which 
the  loss  of  bone  and  soft  tissues  is  great,  and  it  would  almost  seem  advisable 
that  these  small  wounds  should  be  considerably  enlarged,  and  skin  sewn  to 
mucous  membrane  to  make  these  openings  persist  till  secondary  suture  can 
be  safely  undertaken.  The  author  does  not  propose  to  dilate  upon  the  treatment 
of  secondary  haemorrhage. 

Apart  from  this  dental  toilet,  the  chief  role  of  the  dentist  lies  in  controlling 
the  bony  fragments.  The  author  is  disappointed  with  the  results  of  the  so-called 
suspensory  wiring  of  fragments,  which  involves  the  wrong  principle  of  putting 
foreign  bodies  in  contact  with  inflammatory  bone  lesions.  The  facial  surgeon 
has  the  advantage  of  the  orthopaedist,  in  that  his  instrument-maker  is  a  pro- 
fessional colleague  who  has  for  his  goal  the  provision  of  the  best  masticatory 
result.  The  dental  surgeon  must  be  fully  alive  to  the  possibilities  of  his  surgeon 
and  of  surgery  in  general.  Thus,  in  the  early  days  of  bone-grafting,  many 
wide  gaps  of  the  mandible  were  brought  together  by  the  dental  surgeon  in  the 
early  stages  in  order  to  get  bony  union  in  a  shortened  mandibular  arch.  With 
the  rapid  success  of  mandibular  grafting  this  procedure  has  become  extinct, 
and  it  is  the  author's  opinion  that  it  is  rarely  justifiable  to  shorten  the  mandibular 
arch.  The  class  of  case  where  it  is  permissible  is  that  in  which  the  patient 
is  edentulous,  and  the  loss  of  bone  minimal. 

PLANNING  THE  LATE  REPAIR  IN  A  TYPICAL  CASE 

A  man  with  loss  of  the  upper  lip,  say,  arrives  from  France  with  the  remains 
sutured  across  beneath  his  nose  and  possibly  healed  there.  Frequently  the 
first  step  is  to  reconstitute  the  wound  by  the  release  of  the  overstretched  tissues. 
The  mucosa  of  the  lip  stumps  is  then  secured  by  suturing  it  to  skin  over  the 
raw  edges.  This  very  important  measure  should  be  employed  by  the  first 
surgeon  who  sees  the  case  after  injury.  Only  now,  as  a  rule,  is  it  possible  really 


8  PLASTIC    SURGERY 

to  diagnose  the  loss  and  plan  the  restoration.  (Sometimes  this  replacement 
of  the  first  stage  of  any  plastic  operation  can  be  imitated  by  moving  putty  flaps 
upon  the  plaster  cast  as  one  would  the  flesh.)  In  planning  the  restoration, 
junction  is  the  first  consideration,  and  it  is  indeed  fortunate  that  the  best  cos- 
metic results  are,  as  a  rule,  only  to  be  obtained  where  function  has  been  restored. 
Perhaps  the  first  question  that  arises  in  any  case  is  the  relative  expediency  of 
attempting  surgical  repair  or  mechanical  camouflage,  and  a  satisfactory  decision 
can  be  arrived  at  only  as  a  result  of  long  experience.  Sometimes  in  the  end 
the  repair  undertaken  is  a  compromise  between  surgery  and  mechanics,  the 
decision  being  based  on  the  severity  and  multiplicity  of  the  operations  needed 
to  effect  a  surgical  cure,  and  on  the  patient's  lack  of  stamina  ;  or  on  factors 
outside  the  present  discussion.  One  looks  forward  with  confidence  to  a  plastic 
millennium  when,  given  a  healthy  patient  and  no  time  restrictions,  it  will  be 
possible  to  cope  surgically  with  any  reasonable  facial  loss. 

The  restoration  is  designed  from  within  outwards.  The  lining  membrane 
must  be  considered  first,  then  the  supporting  structures,  and  finally  the  skin 
covering. 

Lining  Membrane. — Omission  to  provide  a  lining  membrane  for  mucous 
cavities  has  in  the  past  been  the  supreme  cause  of  plastic  failure.  Kcegan 
quotes  a  President  of  the  Royal  College  of  Surgeons  in  1863,  as  mournfully 
describing  how  a  well-shaped  plastic  nose  is  prone  to  wither  away  on  the  patient's 
face.  The  author  has  seen  examples  of  a  similar  occurrence  in  recent  times, 
for  want  of  a  lining  ;  and  many  cases  of  post-operative  nasal  stenosis,  microstoma, 
and  contracted  eye-socket  are  traceable  to  the  same  cause.  Even  to  this  date 
the  author  has  frequently  to  perform  a  second  rhinoplasty  upon  patients  who, 
during  a  portion  of  their  plastic  career,  proudly  flaunted  new  and  shapely  noses, 
which  gradually  diminished  in  size  as  a  result  of  ulcerative  processes  within. 

Mucous  membrane  is  not  often  available  except  in  the  smaller  mouth 
defects,  and  the  results  of  free  mucosal  grafts  have  been  poor.  Recourse, 
therefore,  is  had  to  skin,  either  in  the  form  of  flaps  or  grafts.  In  its  new  and 
moist  condition  of  existence  the  surface  epithelium  appears  macroscopically 
to  approach  the  mucosal  type.  In  the  nose,  the  formation  of  the  mucosal 
lining  by  swinging  turbinatcs  and  septum  into  the  desired  position  has  been 
successfully  used  on  a  number  of  occasions.  When  not  available,  an  epithelial 
lining  is  usually  provided  by  means  of  cheek  and  bridge  flaps  turned  skin  in- 
wards. If  these  flaps  are  not  available,  their  place  is  taken  by  a  Thiersch  graft. 
Similar  type  flaps  from  the  margin  of  the  defect  or  Thiersch  grafts  are  used 
in  the  rebuilding  of  the  ocular  aspect  of  new  eyelids.  In  the  smaller  lesions 
of  the  oral  cavity,  the  new  cheek  or  lip  is  lined  by  the  advancement  of  mucous 
flaps  from  the  intact  portions.  Mucous  membrane  flaps  are  also  used  to  replace 


PRINCIPLES  9 

losses  of  the  vermilion  border  of  the  lips.  When  sewn  over  the  raw  edge  of 
the  lip  and  thus  exposed  to  the  air,  the  buccal  mucosa  seems  gradually  to  give 
up  the  power  of  secreting  without  losing  its  colour,  and  a  very  natural  appear- 
ance is  produced.  In  larger  losses,  the  method  of  inturned  skin  flaps  from 
the  neighbourhood  is  resorted  to.  It  often  happens  that  these  flaps  are  hair- 
bearing,  a  property  which  they  retain  in  their  new  situation.  The  disability, 
however,  is  not  greatly  complained  of,  and  when  excessive  can  be  over- 
come by  dissecting  off  the  hair-bearing  layer  later  on,  and  Thiersch  grafting. 
The  author  has  utilised  non-hairy  portions  of  forehead  or  of  chest  flaps  turned 
in  as  a  lining  for  a  buccal  restoration.  Several  surgeons  favour  the  grafting 
of  a  separate  flap  of  hairless  epithelium  on  to  the  under-surface  of  the  flap  designed 
to  form  the  outside  covering,  before  the  latter  is  moved  into  position.  This  is 
tedious,  and  a  similar  result  can  be  more  easily  arrived  at  by  the  tube-pedicle 
principle.  Epilation  by  X-rays  is  unsatisfactory  in  the  author's  experience. 
There  is  long  delay.  Permanent  epilation  is  rarely  obtained,  and  when 
obtained  the  skin  is  avascular  and  atonic,  and  burns  are  liable  to  occur  in 
the  process. 

The  fitting  of  an  efficient  denture  upon  a  mandible  robbed  of  its  alveolar 
ridge  usually  depends  on  the  provision  of  a  much-deepened  labiogingival  sulcus 
to  hold  a  flange  of  the  appliance.  Before  the  importance  of  lining  the  deepened 
sulcus  had  been  recognised,  it  was  found  impossible  to  prevent  its  gradual 
obliteration  by  fibrous  tissue.  Now,  thanks  to  development  of  the  Esser  inlay, 
the  sulcus  can  be  permanently  deepened  in  one  small  operation. 

The  Esser  Epithelial  Inlay. — The  provision  of  a  lining  for  a  deepened  sulcus 
was  first  carried  out  by  Esser  (vide  Annals  of  Surgery,  March  1917).  He 
inserted  a  moulded  piece  of  dental  composition  wrapped  round  with  a  Thiersch 
graft  (deep  surface  outwards)  into  a  pocket  dissected  out  subjacent  to  the 
mucosal  lining  of  the  existing  sulcus,  the  whole  operation  being  performed 
through  a  skin  incision.  After  a  suitable  interval  the  bottom  of  the  sulcus 
was  incised,  and  the  mould  removed  per  oram,  leaving  the  skin-lined  cavity  as 
an  extension  of  the  sulcus. 

The  author  having  practised  the  typical  Esser  inlay  with  considerable 
success  and  also  extended  its  principles  to  the  cure  of  ectropic  conditions,  it 
occurred  to  his  Dominion  colleagues  to  simplify  the  method  for  providing  a 
lining  membrane.  Having  discussed  with  the  author  the  possibility  of  intro- 
ducing the  skin-graft  per  oram,  Lieut. -Colonel  C.  W.  Waldron,  C.A.M.C.,  was 
the  first  to  perform  this  modification  in  this  hospital.  He  was  closely  and 
independently  followed  by  Lieut.-Colonel  H.  P.  Pickerill,  O.B.E.,  N.Z.M.C. 

Its  obvious  success  led  to  great  activity  in  the  sectional  dental  departments 
for  its  further  improvement  and  simplification. 


10 


PLASTIC    SURGERY 


The  details  of  the  method  are  as  follows  : 

A  dental  splint  destined  to  control  the  Stent l  is  fitted  to  any  existing  teeth 
or  to  the  alveolar  ridge  (see  figs.  1  and  2),  and  the  sulcus  is  deepened  per  oram 
to  the  satisfaction  of  the  dental  surgeon. 

In  this  operation  all  scar  tissue  must  be  excised,  and  the  knife  must  be 
kept  close  to  the  bone,  so  that  no  loose  soft  tissues  remain  on  the  alveolar  wall 
of  the  sulcus. 

An  impression  of  the  new  sulcus  is  taken  with  warm  Stent,  which  is  made 
to  distend  the  cavity.  When  set,  it  is  adjusted  to  the  dental  splint.  It  is 


Fio.   1. — Epithelial  Inlay.     (The  arrows  mark  the  limit  of  the  skin  graft.) 

then  taken  out  and  completely  covered  with  a  large,  thin,  evenly  cut  Thicrsch 
skin-graft,  deep  surface  outward,  and  is  pressed  firmly  into  the  rawed  sulcus 
and  there  maintained  ten  days  by  the  splint.  Meanwhile  the  dentist  prepares 
his  appliance,  and  must  be  ready  to  fit  it  the  moment  the  Stent  is  removed,  as 
the  cavity  is  liable  to  shrink  if  left  unoccupied  for  any  length  of  time.  As 
an  intermediary  stage  between  the  Stent  and  the  final  appliance,  a  mould  of 
black  gutta-percha  is  sometimes  used. 

This  operation  may  well  be  performed  under  regional  anesthesia.     The 

1  The  dental  composition  used  for  this  purpose  is  that  put  forward  by  Stent,  and  a  mould  composed 
of  it  is  known  us  a  "  !Stent." 


PRINCIPLES 


11 


I.  The  obliterated  Sulcus. 


2.  Incision  close  to  the  bone. 


3.  Sulcus  deepened. 


4.  Skin  graft  on  Stent. 


5.  Graft  on  Stent  in  position. 


7.  Operation  completed. 


6.  Cap  splint  with  horizontal      8.  Ten  days  later.     Stent  removed  :  Sulcus 
adjustable  flange.  permanently  deepened  and  lined. 

Fio.  2. — Stages  in  the  Epithelial  Inlay. 


author  is  of  opinion  that  the  original  method  of  Esser,  difficult  as  it  is,  is  still 
the  method  of  choice  in  a  few  rare  cases. 

A  similar  procedure  has  been  successfully  used  in  the  nasal  cavity,  and  for 
lining  the  ocular  aspect  of  a  new  eyelid. 


12  PLASTIC    SURGERY 

The  principle  of  the  Esser  Inlay  marks  an  epoch  in  surgery,  and  the  oppor- 
tunities for  its  application  are  far  from  exhausted.  A  further  modification 
of  it  is  discussed  in  this  chapter  in  the  pages  devoted  to  "  Coverings." 

Supporting  Structure. — The  importance  of  the  general  contour  of  the  face 
in  the  matter  of  expression  is  only  realised  gradually.  Disappointment  is  in 
store  for  him  who  would  confine  his  repair  to  the  surface  tissues,  heedless  of 
Nature's  lessons  in  architecture.  Theoretically,  the  application  of  one's  ana- 
tomical knowledge  should  suffice  to  point  out  the  value  of  contour,  but  in 
practice  the  realisation  comes  only  by  close  co-operation  with  the  sculptor. 
In  this  matter  of  the  general  form  of  the  part  all  sorts  of  artificial  implantations 
have  been  tried.  Metallic  plates  and  filigrees,  celluloid  plates,  and  injections 
of  liquid  celluloid,  solid  pieces  of  wax,  and  injections  of  molten  wax,  have  all 
been  used  to  build  up  the  missing  contour.  Speaking  generally,  the  use  of  any 
foreign  body  is  to  be  condemned  whenever  it  is  possible  to  substitute  a  graft 
from  the  patient  himself.  Any  form  of  a  foreign  body  is  a  tissue  irritant,  and 
tends  to  give  trouble  early  qr  late,  in  the  attempt  on  the  part  of  the  tissues 
to  remove  it ;  whereas  grafts,  if  successful  in  the  early  stages,  continue  satis- 
factory. One  celluloid  plate  which  was  used  to  replace  a  zygomatic  prominence 
developed  over  it  a  cold  abscess  five  months  after  its  implantation.  The 
healing  had  been  primary,  and  when  the  abscess  burst,  the  skin  again  healed 
over  the  plate.  But  by  far  the  greater  number  of  celluloid  plates  had  to  be 
removed  within  two  months  of  their  insertion. 

Satisfactory  early  results  are  obtained  by  very  cautious  and  repeated 
injections  of  paraffin  wax  in  small  quantities,  but  the  late  results  are  rarely 
good  and  are  often  appalling.  It  is  not. suitable  for  the  larger  restorations, 
and  the  imbedding  of  solid  blocks  of  paraffin  has  not,  in  the  author's  experience, 
been  tolerated.  The  little  experience  the  author  has  had  with  buried  metallic 
or  vulcanite  plates  discourages  further  experiment  with  them.  Professor 
Mat-Bride,  of  the  Imperial  Research  Laboratory,  is  at  present  carrying  out  a 
research  for  the  author  on  the  implantation  of  celloidin  into  the  ears  of  mice. 

There  is  no  royal  road  to  the  fashioning  of  the  facial  scaffold  by  artificial 
means  :  the  surgeon  must  tread  the  hard  and  narrow  way  of  pure  surgery. 
Of  the  various  autologous  grafts  available  one  has  had  enough  experience  to 
form  some  conclusions.  It  may  be  laid  down  as  a  guiding  maxim  that  the 
replacement  should  be  as  nearly  as  possible  in  terms  of  the  tissues  lost,  i.e. 
bone  for  bone,  cartilage  for  cartilage,  fat  for  fat,  etc.  The  use  of  bone-grafts 
has  been  narrowed  down  to  the  replacement  of  mandibular  and  malar  losses. 

Cartilage  for  large  cosmetic  purposes  stands  unrivalled.  It  is  available  in 
sufficient  quantity,  is  easily  fashioned  to  the  desired  shape,  and,  what  is  most 
important,  remains  permanently  in  the  shape  and  size  in  which  it  is  imbedded, 


PRINCIPLES  13 

with  the  exception  that  if  one  perichondrial  surface  only  is  left,  the  graft  tends 
to  bend,  the  perichondrium  occupying  the  concavity  ;  and  this  property  of 
cartilage  is  utilised  by  the  surgeon  to  obtain  a  curve  in  such  positions  as  the 
eyelids  or  the  mandible.  In  cases  of  suppuration,  there  may  be  necrosis  of 
part  of  the  cartilage  and  a  corresponding  secondary  deformity  may  arise.  This 
is  also  the  case  when  a  part  of  the  cartilage  is  left  exposed  in  a  mucous  cavity. 
The  clinical  evidence  of  the  permanence  of  cartilage  is  borne  out  by  the  ex- 
perimental work  of  Staige  Davis  (Annals  of  Surgery,  1917,  vol.  Ixvi,  p.  88), 
and  by  the  histological  work  of  Keith  and  Murray.  (See  figs.  3,  4,  and  5,  6.) 

The  method  of  obtaining  cartilage  is  a  modification  of  that  suggested  by 
Nelaton.  A  six-inch  vertical  incision  is  made  over  the  costal  cartilages  having 
its  middle  opposite  the  seventh,  and  is  deepened  through  the  rectus  muscle, 
which  is  widely  retracted.  The  seventh,  or  the  seventh  and  eighth  cartilages, 
are  dissected  free  and  removed  with  perichondrium  intact,  and  are  at  once 
transferred,  wrapped  in  sterile  gauze,  to  a  table  with  three  edges  raised  to  prevent 
disaster  during  the  shaping  of  the  graft.  The  wound  is  sutured  by  an  assistant, 
and  the  thorax  strapped  as  for  a  fractured  rib  in  order  to  avoid  pain,  which  is 
otherwise  likely  to  be  severe.  Meanwhile,  the  surgeon  shapes  his  graft  with 
a  scalpel,  leaving  the  perichondrium  on  one  surface  in  cases  where  a  curve  or 
a  spring  effect  is  desired.  The  graft  is  put  into  place  and  the  wound  sutured 
without  drainage,  except  in  those  cases  where  a  lijematoma  appears  likely, 
and  any  excess  of  cartilage  is  inserted  under  the  skin  of  the  upper  abdomen 
as  a  store  for  use  in  future  operations,  the  pain  of  a  further  rib  excision  being 
thus  avoided.  This  hoard  of  cartilage  may  prove  of  use  to  others  if  not  wholly 
required  by  the  patient  himself.  The  question  of  homologous  grafts  opened 
up  by  this  procedure  is  of  extreme  interest,  and  a  definite  decision  as  to  their 
expediency  has  not  yet  been  arrived  at.  It  goes  without  saying  that  the  donor 
must  be  proved  free  from  syphilis. 

In  this  connection  one  had  the  opportunity  of  furnishing  material  from 
various  autologous  and  homologous  cartilage  grafts  to  Professor  Keith.  Dr. 
J.  Alexander  Murray  undertook  this  research  for  Professor  Keith.  Illustra- 
tions (figs.  3  and  5)  of  two  of  his  sections  are  given.  Captain  V-  -  and 
Lieut.  S—  were  operated  upon  the  same  day.  Some  cartilage  from 
Captain  V-  -  was  put  into  the  subcutaneous  abdominal  tissues  of  both  Captain 
V-  -  (autologous)  and  Lieut.  S—  -  (homologous).  After  eighteen  months 
the  opportunity  arose  of  removing  these  grafts.  There  is  no  doubt  that  in 
both  cases  the  cartilage  is  alive  and  active,  but  Dr.  Murray  finds  that  the  cells 
in  the  homologous  (Lieut.  S—  -)  are  more  vacuolated  and  show  more  cal- 
careous changes  (i.e.  degenerative)  than  do  those  of  Captain  V-  — .  (See  figs. 
4  and  6.) 


14  PLASTIC    SURGERY 

It  should  be  noted  that  neither  of  these  two  grafts  was  submitted  to  stress 
or  strain  in  the  region  where  it  was  buried.  The  author  hopes  that  when 
a  cartilage  graft  is  put  under  fairly  normal  conditions  of  functional  existence, 
such  as  is  obtained  when  it  is  employed  in  nasal  reconstruction,  it  will  persist 
in  the  form  and  position  given  it.  Certainly,  in  the  author's  experience,  no 
changes  other  than  curvature  toward  the  perichondrial  surface  have  occurred 
in  any  of  his  successful  autologous  grafts,  and  in  only  a  few  of  the  homologous 
grafts  has  the  cartilage  become  replaced  by  fibrous  tissue  as  a  late  sequel.  Three 
years  is  the  longest  that  the  author  has  had  a  graft  under  observation.  Even 
if  partial  calcification  should  occur  this  does  not  depose  cartilage  from  its  place 
as  facile  princeps  among  facial  supports. 

The  insertion  of  a  cartilage  graft  may  constitute  a  whole  operation,  as, 
for  instance,  when  it  is  introduced  subcutaneously  to  elevate  a  depressed  nasal 
bridge ;  or  it  may  form  a  stage  in  a  series  of  operations.  In  rhinoplasty  (author's 
method)  the  cartilage  support  for  the  nasal  bridge  is  usually  inserted  subcu- 
taneously under  the  skin  over  the  glabella — the  skin  destined  for  the  lining 
of  the  new  nose — and  is  swung  down  attached  to  the  deep  surface  of  this  when 
it  is  turned  down  at  a  later  stage. 

In  the  method  suggested  by  Nelaton  the  support  is  swung  down  on  the 
deep  surface  of  the  flap  designed  to  form  the  covering  of  the  nose,  a  method 
hampering  free  manipulation  of  the  graft  with  a  view  to  fixing  it  in  the  best 
position. 

It  is  sometimes  convenient  to  employ  yet  a  fourth  method,  in  which  the 
support  is  built  into  its  final  position  between  the  lining  and  the  covering,  before 
the  flap  is  raised.  This  procedure  has  been  successfully  followed  in  the  replace- 
ment of  facial  losses  by  pedicled  chest-flaps.  The  part  is  fashioned  upon  the 
chest  by  the  manipulation  of  small  skin-flaps,  the  cartilage  graft  being  introduced 
between  two  layers  of  a  flap  doubled  upon  itself,  or  between  the  flap  and  a 
Thiersch  covering  of  its  under-surface. 

When  a  softer  contour  is  desired  than  would  be  provided  by  cartilage,  local 
fat  and  muscle  flaps  are  used  to  fill  the  smaller  hollows.  The  use  of  fat-flaps 
is  most  satisfactory,  and  should  be  employed  for  all  depressed  scars.  They 
are  discussed  later  in  this  chapter,  and  examples  of  their  use  are  given  in  the 
section  on  Cheeks.  For  larger  hollows,  free  fat  and  muscle  grafts  are  used  ; 
these  are  naturally  more  uncertain  of  result.  All  the  author  feels  it  possible 
to  say  of  fat-grafts  is,  that  when  successful,  the  result  is  very  satisfactory,  arc! 
alteration  of  the  contour  from  absorption  has  not  occurred  to  any  appreciable 
extent  while  the  case  has  been  under  observation.  It  is  not  yet  established 
lm\v  they  will  be  affected  in  conditions  of  wasting,  or  in  old  age.  The  fat-graft, 
however,  owing  to  fat  necrosis,  often  undergoes  a  partial  absorption,  which  is 


PRINCIPLES 


15 


FIGS.  3  and  4. —  V.  (Autologous  graft.) — No  reaction  at  cut  surface. 
There  is  only  a  very  shallow  layer  1-2  cells  deep  of  dead 
cartilage  cells.  Under  the  old  perichondrial  surface  the  cells  have  remained  healthy.  In  the 
central  parts  of  the  cartilage  the  cells  are  arranged  in  small  groups  with  deeply  stained  areas 
of  matrix  around  them — very  much  the  condition  seen  in  normal  adult  costal  cartilage.  The 
general  matrix  stains  more  faintly  and  is  generally  faintly  fibrillated.  This  is  not  excessive. 


»  V 

-V...       v 


>-> 

•»-• 

FIGS.   5  and  0. —  V.  rib.  cart,  in  S.  (Homologous  graft.) — The 

cartilage  cells  are  throughout  more  active,  and  occur  not  in  -$•• 

clumps,    as   in    the   donor,    but   in    long    columns — towards  "'•*„.  .».,      ,*• 

the  perichondrial  surface  isolated   cells  of  spindle  form  are 

most  numerous.     In  the  deeper  parts  rounded  groups  with 

darkly-stained  secondary  capsules  occur  also.    Fibrillation  of  the  general  matrix  is  fairly  frequent, 

but  not  excessive.     It  looks  as  if  the  graft  in  the  strange  soil  had  proliferated  more  actively,  and 

was  still  remote  from  the  quiescent  stage  which  is  seen  in  the  autologous  graft. 


/ 


c. 


16  PLASTIC    SURGERY 

carried  to  greater  lengths  if  the  products  of  this  disintegration  become  infected  ; 
but  even  in  this  latter  unfortunate  event  not  all  the  fat  (or  muscle)  comes  away, 
and  eventually  there  is  left  sufficient  substance  to  aid  very  materially  in  any 
future  work  on  the  part.  Fat-grafts  are  frequently  recommended  as  a  pre- 
liminary to  a  bone-graft,  and,  in  the  author's  opinion,  rightly  so. 

Of  other  ways  of  building  up  the  facial  contour,  the  author  would  like  to 
draw  attention  to  the  following,  which  are  available  only  in  certain  localities. 
The  malar  prominence  may  be  simulated  satisfactorily  by  the  svibcutaneous 
advancement  of  the  adjacent  temporal  muscle,  as  described  on  p.  55.  In 
partial  or  complete  rhinoplasty,  considerable  help  is  sometimes  obtained  in 
building  up  the  sides  or  bridge  of  the  nose  by  the  use  of  turbinate  grafts  and 
muco-cartilaginous  flaps  from  the  septum,  before  the  skin  covering  is  applied. 

With  regard  to  anterior  palatal  perforations  involving  loss  of  the  premaxilla, 
it  is  not  the  author's  practice  to  attempt  a  purely  surgical  repair.  The  goal 
of  obtaining  efficient  mastication  is  more  certainly  achieved  by  a  mechanical 
repair  at  the  hands  of  the  dental  surgeon. 

The  Covering  Tissues. — In  the  provision  of  a  covering  there  is  little  choice 
in  the  way  of  material :  one  has  to  decide  between  using  a  skin-flap  or  one  of 
the  types  of  skin-graft. 

Generally  speaking,  the  application  of  skin-grafts  is  limited  to  superficial 
lesions.  Where  a  gap  is  to  be  bridged,  or  where  tension  is  likely  to  occur,  a 
skin-flap  is  indicated. 

Skin-grafts. — The  preparation  and  manipulation  of  the  various  forms  of 
skin-grafts  with  a  nice  judgment  in  their  use  constitute  an  important  part  of 
the  plastic  surgeon's  stock-in-trade. 

(1)  Thiersch  grafts. — In  plastic  work  the  simple  Thiersch  graft  is  not  of 
very  wide  application,  but  in  specialised  forms  its  use  covers  a  very  wide  range. 
The  Esser  Inlay  has  been  already  fully  described.     The  author  has  adapted 
the  Esser  inlay  to  surface  use  in  the  method  known  as  the  "  Epithelial  Outlay," 
which  finds  its  most  important  application  in  his  operation  for  the  relief  of 
ectropion  of  the  lids,  as  follows  :    An  incision  is  made,  skirting  the  lid  edge, 
and  the  lid  liberated  by  dissecting  freely  till  closure  can  be  effected  without 
tension.     In  the  resulting  cavity  is  buried  a  closely  fitting  Stent  mould  covered 
with  a  Thiersch  graft,  over  which  the  edges  of  the  incision  are  sewn  with  horse- 
hair, the  sutures  taking  up  the  edges  of  the  skin-graft.     After  some  eight  days 
the  Stent  either  falls  out  or  is  removed,  and  the  lid  falls  easily  into  position. 
See  section  on  Burns,  pp.  376-7,  and  fig.  7. 

The  principle  is  applicable  in  many  other  localities,  notably  in  cases  of 
adhesions  between  the  pinna  and  the  scalp  following  burns. 

(2)  H'olje  and  W hole-thickness  gmJts.~T\\e  factors  determining  the  successful 


PRINCIPLES 


17 


use  of  these  grafts  are  somewhat  obscure,  but  it  may  be  laid  down  that  firm 
apposition  and  accurate  coaptation  of  the  edges  are  essential.  It  would  seem 
also  that  tension  assists — tension  of  a  degree  comparable  with  that  obtaining 
in  the  area  from  which  the  graft  is  taken.  Apposition  is  most  easily  achieved 
and  maintained  when  bone  or  cartilage  closely  underlies  the  area  to  be  covered, 


IMCiSION, 
JUST     ABOVE     CiLiflRY       BORDER 


SCM  CRAFT  IN  POSITION 
SHOWING  SUTURES  THROUGH 
EYELID  *f(D  TMIERSCM  GRAFT 


UPPER     ADD    LOWER     EDGES   OF 
IMCISIOM     SUTURED     OVER     STEMT 


INCISION      ALONG      LINE     OF     3UTURE5 


EYELID       LOWERED        SHOWING 
OUTLINE     OF    TMIEA5CM      CRAFT 


FIG.  7. — Stages  in  the  Epithelial  Outlay  Operation. 

as  in  the  forehead  or  nose ;    and  it  is  only  in  such  regions  that  immobility— 
obviously  a  desirable  factor — is  obtainable. 

The  fact  that  a  large  graft  is  less  likely  to  take  in  its  entirety  than  is  a 
small  one  is  improbably  due  to  any  inherent  disability  in  the  question  of  size  ; 
it  is  very  possibly  explained  by  the  fact  that  the  above-mentioned  factors  are 
more  difficult  of  attainment  in  a  large  graft. 

2 


18  PLASTIC    SURGERY 

These  grafts  are  in  routine  use  for  covering  raw  areas  upon  the  forehead 
left  by  the  removal  of  rhinoplastic  flaps,  and  for  providing  a  healthy  covering 
for  the  nose  in  cases  of  severe  facial  burns.  For  small  areas  the  skin  may  be 
taken  from  the  back  of  the  neck ;  for  areas  up  to  two  inches  in  diameter  the 
skin  is  taken  from  over  the  biceps — the  conditions  of  tension  in  this  region 
being  suitable.  Larger  grafts  are  taken  from  the  chest  or  abdomen. 

The  question  as  to  whether  the  graft  shall  be  skin-deep  or  contain  a  layer 
of  fat  is  determined  by  the  needs  of  the  case,  there  being  no  marked  disparity 
between  the  two  in  the  matter  of  viability.  If  hair  is  required  the  scalp  in 
the  post-auricular  region  is  employed ;  the  author  has  successfully  used  whole- 
thickness  grafts  from  this  region  in  the  replacement  of  eyebrows  lost  through 
burns.  (Case  No.  338,  p.  356.)  The  details  of  the  method  employed  in  a  typical 
case  may  be  of  interest ;  the  example  taken  is  the  grafting  of  the  raw  area  on 
the  forehead  after  a  rhinoplasty,  where  the  returned  pedicle  is  inadequate  wholly 
to  cover  the  defect. 

By  the  time  the  pedicle  is  returned  the  area  is  covered  by  healthy  granu- 
lations. It  is  customary  to  scrape  these  away,  as  in  cases  where  they  have 
been  left  the  patients  have  complained  of  a  feeling  of  constriction  round  the 
head,  presumably  caused  by  the  contraction  of  this  large  mass  of  scar  tissue. 
The  area  to  be  covered  is  accurately  mapped  out  with  tinfoil,  and  the  foil  outlined 
upon  the  chest  or  upper  arm  with  the  point  of  the  knife.  The  graft  is  then 
dissected  up,  care  being  exercised  to  avoid  bruising  it  with  forceps.  It  shrinks 
greatly  as  it  is  freed.  If  the  bone  is  exposed  on  the  forehead,  the  graft  is  cut 
so  as  to  contain  a  layer  of  fat,  for  though  a  graft  will  often  take  upon  bare  bone 
it  is  liable  to  adhere  too  closely  for  normal  movement  unless  fat  intervenes. 
Fixation  sutures  are  now  inserted  at  the  corners  of  the  graft,  so  as  to  ensure 
symmetrical  tension,  and  accurate  coaptation  of  the  edges  is  then  effected  with 
continuous  horsehair  sutures.  Meanwhile,  an  assistant  has  prepared  a  Stent- 
backing  to  the  tinfoil  map  of  the  area,  and  this  is  firmly  pressed  into  the 
slight  depression  now  occupied  by  the  graft  while  still  in  a  semi-solid  condition, 
and  the  whole  firmly  bandaged  to  the  head.  The  pressure  is  maintained  for 
about  forty-eight  hours,  and  the  graft  then  observed.  If  the  prognosis  is 
favourable,  it  will  by  this  time  have  assumed  a  somewhat  forbidding  livid  and 
mottled  appearance,  and  will  have  swelled  considerably.  Any  portions  that 
have  died  will  appear  white  and  opaque,  or  black  (underiun  by  clot).  Stitches 
are  removed  about  the  fifth  day,  and  massage  is  applied  after  about  three  weeks. 

Skin-flaps. — The  delineation  and  manipulation  of  skin-flaps  constitute 
the  ABC  of  the  plastic  surgeon's  metier.  The  subject  has  been  worn  threadbare 
in  countless  textbooks,  and  it  is  not  proposed  here  to  give  a  compendium  of  all 
possible  flaps. 


PRINCIPLES 


19 


Essentially,  all  flaps  are  similar,  and  consist  of  two  parts — the  part  chiefly 
concerned  with  the  traffic  in  circulatory  fluids,  and  the  part  available  for  plastic 
use. 

Broadly  speaking,  flaps  may  be  grouped  as  follows  : 

A.  Advancing  flaps. 

B.  Transposed  flaps. 

The  differences  are  portrayed  in  the  following  diagrams  illustrating  their 
use,  the  pages  devoted  thereto  being  intended  as  part  of  a  glossary  for  terms 
used  later  in  the  book. 

The  majority  of  the  terms  used  are  self-explanatory.  "  Ascending " 
flaps  are  those  in  which  the  skin  from  below  the  defect  is  swung  up  on  a  base 
roughly  on  the  same  level  as  the  defect.  Thus,  an  "  ascending  neck-flap  "  is 
one  the  body  of  which  has  been  raised  from  the  neck,  the  base  being,  for  instance, 
on  the  lateral  aspect  of  the  chin. 

In  actual  use,  modifications  of  these  flaps  are  employed  according  to  the 
locality ;  thus,  for  rhinoplasty,  instead  of  the  traditional  forehead  bridge  flap, 
the  author  is  now  employing  a  long  flap  containing  the  anterior  branch  of  the 
superficial  temporal  artery,  based  on  the  pre-auricular  region.  The  middle 
portion  of  the  flap  is  "  tubed  "  (see  figs.  p.  21),  and  when  severed  from  the  plastic 
portion  after  some  ten  days,  is  opened  out  and  replaced  upon  the  forehead, 
leaving  a  raw  area  no  larger  than  that  left  by  the  Indian  method.  The  blood- 
supply  of  this  flap  is  remarkable ;  its  nourishing  vessel  spouts  freely  when  the 
tubed  portion  is  severed  from  the  new  nose. 

The  transposed  flap  (imbedded  type)  is  usually  employed  about  the  eyes 
and  mouth,  a  depression  of  the  buccal  orifice  being  relieved  by  transposing  a 
flap  from  the  corresponding  naso-labial  fold  to  a  position  below  the  orifice,  the 
flap  in  this  case  being  a  "  descending  naso-labial  flap."  If  the  tissue  in  the 
naso-labial  fold  is  scarred  or  otherwise  unsuitable,  an  ascending  neck-flap  can  be 
employed  to  produce,  in  a  less  degree,  a  similar  result.  But  in  this  case  the 
flap  must  be  taken  from  the  side  of  the  neck,  being  swung  through  ninety  degrees 
from  a  vertical  to  a  horizontal  position  ;  otherwise  the  gain  of  skin  below  the 

Fio.  8.— Flaps. 
A.     ADVANCING   FLAPS 
1.     SIMPLE  ADVANCEMENT  (Forward  type). 


Defects. 


Incisions  and  Excision. 


Flap  A.     Advancing. 


Suture. 


PLASTIC    SURGERY 


2.  "  V.  Y.1'  ADVANCEMENT. 


A- 


.A' 


Defect.  Incision.  Suture. 

3.     SWINGING  ADVANCEMENT  (Combination  of  Forward  and  Lateral  Advancement). 


Defect. 


Incision. 


Suture. 


B.     TRANSPOSED     FLAPS 


1.     IMBEDDED. 


Defect. 

2.     BRIDGE  FLAPS. 

(a)  Simple  Pedicle. 


Incision. 


""^     A 


Suture. 


Eyebrows  lacking. 


Incisions. 


Suture. 


PRINCIPLES 

(6)  With  Pedicle  "tubed."     (Author's  Method.) 

^  L 


21 


Detect. 


Flap  Pedicle  "  tubed." 


Flap  swinging  upon  Pedicle. 


Suture. 


Pedicle  being  returned  and  unrolled. 


PLASTIC    SURGERY 

mouth  has  to  be  written  off  against  the  loss  which  occurs  when  the  bed  from 
which  it  was  raised  is  closed. 

The  use  of  flaps  is  not  confined  wholly  to  the  provision  of  a  skin  covering. 
In  many  cases  the  flap  is  used  as  a  vehicle  for  the  introduction  of  a  cartilaginous 
support  previously  imbedded  in  it,  as  discussed  earlier  in  this  chapter.  A 
typical  example  occurs  in  the  reconstruction  of  the  nose,  in  which  the  bridge 
support — a  cartilage  rod— is  imbedded  under  the  skin  destined  to  form  the 
lining  of  the  vestibule,  and  swung  down  upon  its  deep  surface  to  occupy  a  position 
between  the  lining  and  the  covering.  (Figs.  388  and  389.)  A  similar  principle 
has  been  employed  in  the  reconstruction  of  the  chin  in  a  chest-flap  previous 
to  its  elevation. 

The  plastic  surgeon  must  early  acquire  an  instinct  for  forecasting  the 
viability  of  the  flaps  he  uses.  Apart  from  those  containing  a  definite  artery 
such  as  the  superficial  temporal  (the  base  for  which  may  be  cut  quite  narrow), 
generally  speaking  the  base  should  be  at  least  as  wide  as  any  other  part  of  the 
flap.  The  length  which  may  be  safely  taken  varies  with  the  breadth  and  depth 
-particularly  the  depth.  If  the  depth  includes  no  more  than  the  true  skin,  it 
seems  in  practice  safer  to  use  a  graft  than  a  flap  :  a  skin-deep  flap  of  any  length 
is  found  rapidly  to  become  cedematous,  and  often  dies  from  the  obstruction 
thus  caused.  The  explanation  perhaps  lies  in  the  fact  that  egress  for  the  products 
of  metabolism  is  inadequate.  In  the  early  stages  of  a  free  graft  the  ebb  and 
the  flow  of  tissue-fluids  are  conditioned  by  the  same  factor,  the  osmosis  resulting 
from  the  biochemical  activity  of  the  cells  :  the  matter  is  not  complicated  by 
the  continued  arrival  of  fluid  from  without,  and  marked  congestion  does  not 
arise. 

In  the  event  of  oedema  of  an  intensity  likely  to  jeopardise  the  life  of  the 
flap,  it  has  been  taught  that  multiple  punctures  are  indicated.  The  author 
prefers  gentle  efferent  massage,  which  avoids  the  creation  of  minute  thrombi 
and  of  extra  channels  of  infection,  and  which  helps  to  dissipate  the  commencing 
lymphatic  and  venous  stasis.  Furthermore,  hot  moist  dressings  have  a  definite 
effect  in  helping  the  sluggish  corpuscle  back  to  the  normal  circulation.  It  is 
the  author's  opinion  that  in  a  flap  thrombosis  may  be  caused  by  merely  a  few 
minutes'  pressure,  as  from  a  kink. 

The  viability  of  flaps  varies  greatly  in  different  regions.  Those  based 
about  the  chin  are  never  a  cause  of  anxiety,  whereas  ascending  flaps  from  the 
neck  contain  the  possibilities  of  disaster  and  must  be  treated  with  the  greatest 
respect.  It  is  of  advantage,  when  dealing  with  a  flap  whose  chances  of  life  are 
precarious,  to  wrap  it  with  a  hot  saline  pad  during  the  ligature  of  arteries,  etc. 
It  goes  without  saying  that  in  cutting  a  flap  one  should,  if  possible,  avoid  its 
containing  scar  tissue  :  in  the  altered  condition  of  existence  the  scar  is  liable 


PRINCIPLES  23 

to  swell,  not  only  forming  ah  unsightly  blemish  but  being  highly  prejudicial 
to  the  blood  supply. 

Among  other  conditions  which  are  prone  to  affect  the  viability  of  a  flap, 
the  surface  to  which  it  is  applied  exercises  a  most  powerful  influence.  It  has 
been  observed  that  flaps  containing  scar  tissue  which  would  certainly  die  if  im- 
planted upon  the  face,  will  often  live  upon  the  same  base  if  applied  to  form  the 
lining  of  a  mucous  cavity,  where  warmth  and  moisture  are  present. 

In  this  question  of  viability  of  flaps  the  personal  equation  of  the  patient 
and  of  the  surgeon  comes  strongly  to  the  fore. 


ANESTHESIA     (CAPTAIN    WADE) 

The  administration  of  anaesthetics  for  the  plastic  surgeon  is  a  highly  special- 
ised procedure. 

To  begin  with,  the  majority  of  plastic  operations  are  unavoidably  long  ; 

tthe  insertion  of  sutures  alone  is  apt  to  occupy  a  skilled  surgeon  more  than  half 
an  hour.  The  type  of  patient,  too,  is  often  unfavourable,  especially  in  cases 
of  wounds  involving  the  oral  cavity,  where  a  long  convalescence  has  been 
hampered  by  ill  nourishment. 

Moreover,  the  airway,  in  many  cases,  is  strangely  distorted  in  some  part 
of  its  course  ;  and,  in  addition,  the  surgeon  must  perforce  trespass  upon  the 
territory  usually  regarded  by  the  anaesthetist  as  his  own. 

Evidently,  therefore,  there  is  scope  for  any  and  every  device  that  will 
diminish  effort  for  the  patient  and  the  anaesthetist,  and  bring  the  prolonged 
strain  within  the  limits  of  endurance. 

An  arrangement  must  be  come  to  also  by  which  the  surgeon  is  spared  the 
disability  of  disputing  the  possession  of  the  parts. 

For  large  operations  upon  the  mouth  region,  intra-tracheal  administration 
in  some  form  has  been  adopted  as  a  routine.  Where  the  form  of  the  parts 
permits,  a  catheter  is  introduced  into  the  trachea  through  a  Mosher's  laryngeal 
speculum  under  the  guidance  of  vision.  This  may  be  prevented  by  the  pro- 
jection of  splints  fitted  to  the  upper  jaw,  or  by  conditions  of  microstoma,  trismus, 
contracted  mandibular  arch,  etc.,  in  which  case  intra-tracheal  anaesthesia  is 
effected  by  means  of  a  laryngotomy,  or,  in  rare  instances,  a  tracheotomy.  Ether 
t  is  the  intra-tracheal  anaesthetic  of  choice.  It  is  given  under  positive  pressure, 
being  carried  either  by  a  stream  of  oxygen  from  a  large  cylinder  or  by  a  stream 
of  air  propelled  by  a  small  electrically  driven  motor,  either  way  leaving  the 
anaesthetist  the  use  of  both  his  hands  for  the  manipulation  of  the  stop-cocks,  etc. 

In  smaller  operations  upon  the  mouth,  it  is  found  convenient  to  use  a  nasal 


_u  PLASTIC    SURGERY 

tube  or  tubes,  the  pharynx  being  shut  off  by  plugging  the  hinder  portion  of  the 
buccal  cavity  with  loose  gauze  which  is  renewed  from  time  to  time. 

When  the  operation  is  upon  the  nose,  the  nose  and  post-nasal  space  are 
plugged,  and  a  Hewitt's  airway  is  employed. 

In  all  these  cases,  the  anaesthetic  is  conveyed  through  a  tube  long  enough 
to  avoid  interference  with  the  surgeon,  the  means  of  propulsion  being  as  in 
the  intra-tracheal  method. 

Administration  by  positive  pressure  undoubtedly  relieves  the  patient  of 
much  of  the  strain  of  a  long  operation,  and  the  ease  with  which  pure  oxygen 
or  air  can  be  substituted  for  anaesthetic  through  the  clear  airway  achieved  by 
the  methods  described,  diminishes  the  stress  associated  with  cyanosis  to  a 
minimum.  The  difficulties  consequent  upon  the  routine  adoption  of  these 
methods  are  easily  overcome  with  practice.  The  anaesthetist  must  learn  to 
depend  almost  solely  on  the  respiratory  movements  and  the  pulse  as  his  guide, 
with  rare  peeps  at  the  pupil. 

I  propose  here  to  discuss  some  of  our  methods  in  more  detail  : 

Chloroform  and  Oxygen  in  the  Sitting-up  Position. — This  method  was  intro- 
duced to  us  by  Colonel  J.  F.  W.  Silk,  Consultant  Anaesthetist  to  the  War  Office, 
in  September  1916.  It  is  most  suitable  for  upper  lip  operations — with  or 
without  loss  of  continuity  in  the  maxilla.  It  is  also  useful  for  those  cases 
of  extensive  loss  in  the  mandible  where  the  fragments  cannot  be  held  by 
suitable  splints.  The  advantages  of  the  method  are,  firstly,  that  the  blood 
flows  forward  out  of  the  mouth  ;  secondly,  there  is  less  bleeding  ;  thirdly,  the 
surgeon  has  a  very  good  view  of  the  patient's  face.  But  it  is  certainly  a  tiring 
position  in  which  to  operate. 

In  my  experience,  with  healthy  men  it  is  a  safe  form  of  anaesthesia.  In 
200  cases  I  have  never  had  to  alter  the  position  during  the  early  stages.  Very 
occasionally  they  become  faint  towards  the  end  of  long  operations  and  have 
to  be  lowered  to  the  horizontal,  where  they  quickly  recover.  A  very  light  anaes- 
thesia is  required  after  the  first  half-hour.  In  some  cases  they  pass  into  a  stage 
of  analgesia,  during  which  they  will  answer  remarks  quite  sensibly  for  half  an 
hour  or  more  before  the  operation  is  finished. 

Technique.—  One  end  of  the  operating-table  must  be  capable  of  being  raised 
to  the  perpendicular,  and  must  be  long  enough  to  reach  to  the  patient's  shoulders 
in  this  position.  A  suitable  head-rest  must  also  be  attached.  Induction  is 
carried  out  in  the  sitting  position,  the  back  of  the  table  being  raised  to  just 
short  of  the  perpendicular.  When  induction  is  completed  the  head  is  bound 
firmly  to  the  head-rest.  The  position  of  the  head  is  important ;  if  it  leans  too 
far  back  blood  will  flow  into  the  fauces,  if  too  far  forward  the  airway  may  be 
obstructed.  It  is  sometimes  easier  to  get  the  best  position  by  adjusting  the 


PRINCIPLES  25 

trunk  to  the  head.  When  this  is  satisfactory,  and  the  patient  is  breathing  easily, 
a  No.  10  rubber  catheter  is  passed  down  one  nostril  to  the  pharynx.  The 
catheter  is  connected  by  a  suitable  length  of  rubber  tubing  to  a  Shipway's  warm 
ether  and  chloroform  apparatus,  to  which  an  oxygen  cylinder  has  been  attached, 
and  the  oxygen  made  to  pass  through  the  chloroform  bottle  at  the  required 
rate.  The  oxygen  should  always  be  turned  on  before  the  rubber  tube  from 
the  catheter  is  connected  to  the  apparatus.  As  a  rule,  this  is  a  very  convenient 
method  for  the  anaesthetist,  but  occasionally  the  jaw  requires  support.  If 
anaesthesia  becomes  deeper  than  the  operation  requires,  the  oxygen  rate  can 
be  slowed  or  the  rubber  tube  from  the  catheter  disconnected  from  the  apparatus 
for  a  time,  or  connected  direct  to  the  oxygen  if  necessary. 

The  Nasal  Tube. — This  was  described  by  my  colleague,  Captain  J.  C.  Clayton, 
in  the  Lancet. 

I  always  use  the  largest  tube  (size  20)  which  it  is  possible  to  pass  down  a 
nostril.  If  the  tube  is  cut  to  a  blunt  point  it  will  be  found  to  pass  more  easily. 
If  there  is  difficulty  in  passing  one  of  the  required  size,  it  is  better  to  pass  a 
smaller  one  first,  leave  it  in  place  a  few  seconds,  and  then  try  the  larger  one 
again  ;  in  most  cases  this  can  now  be  passed  easily. 

One  of  the  objections  to  this  method  is  that  the  tube  is  liable  to  kink  at 
the  level  of  the  ala.  I  have  overcome  this  by  cutting  the  nasal  tube  short  at 
the  ala,  and  inserting  into  it  one  end  of  a  right-angled  metal  connection  of  the 
same  bore  as  the  tube.  The  other  end  of  the  metal  connection  is  joined  directly 
to  the  funnel-end  of  a  Kahn's  tube  by  a  short  length  of  rubber  tubing. 

This  arrangement  has  two  advantages  :  firstly,  it  provides  a  shorter  length 
of  tubing  for  the  patient  to  breathe  through ;  and,  secondly,  the  Kahn's  tube, 
being  metal,  cannot  be  inadvertently  compressed  by  the  surgeon,  and  thus 
a  clear  airway  is  assured,  always  provided  that  the  end  of  the  tube  is  in  its 
proper  place  just  above  the  epiglottis  and  that  the  tube  is  not  flattened  too 
much  in  its  passage  through  the  nose. 

The  mouth  and  pharynx  are  then  loosely  packed  with  gauze  so  as  not  to 
compress  the  tube.  The  operation  should  not  be  commenced  till  the  patient 
is  breathing  comfortably.  Anaesthesia  can  be  maintained,  either  by  dropping 
chloroform  on  to  a  layer  of  house-flannel  stretched  over  the  funnel,  or  by  blowing 
a  warm  ether  or  chloroform  and  ether  into  the  funnel  from  a  Shipway  apparatus. 

In  some  cases  where  the  airway  is  just  not  sufficient  there  may  be  some 
cyanosis.  This  can  be  corrected  by  giving  oxygen  when  necessary.  It  is  very 
often  necessary  to  support  the  jaw. 

This  method  is  very  useful  for  lip  plastics,  provided  that  the  tube  is  not 
in  the  surgeon's  way  ;  and  for  epithelial  inlays  and  cleft  palate  operations. 

In  the  last-named  I  prefer  to  give  chloroform  or  chloroform  and  ether 


26  PLASTIC    SURGERY 

from  a  Shipway  apparatus,  through  a  catheter  passed  down  the  nose  to  the 
pharynx.  The  patient's  shoulders  are  raised  and  the  head  fully  extended.  In 
this  position  it  is  impossible  for  the  blood  to  enter  the  larynx.  The  difficulty 
is  to  keep  the  patient  from  coughing.  This  can  be  avoided  by  resting  the  little 
finger  of  the  hand  holding  up  the  jaw  on  the  larynx  when  any  swallowing  move- 
ment— the  prelude  to  a  cough — is  at  once  appreciated. 

The  choice  between  this  and  the  sitting-up  position,  provided  the  patient 
is  healthy,  rests  entirely  with  the  surgeon. 

In  operations  for  reconstructing  the  chin  or  lower  lip,  where  there  is  ex- 
tensive loss  of  the  mandible  and  the  fragments  are  not  controlled  by  splints, 
there  is  no  support  for  the  base  of  the  tongue,  and  it  is  very  difficult  to  maintain 
a  clear  airway.  Laryngotomy  or  tracheotomy  is  the  simplest  way  out  of  the 
difficulty,  but  there  are  two  possible  objections  to  employing  either.  The 
patient  will  probably  require  more  than  one  operation  or  the  surgeon  may 
wish  to  take  a  flap  from  the  neck.  I  have  only  employed  laryngotomy  once 
in  these  cases,  and  have  found  one  or  other  of  the  following  methods  satisfactory. 

(1)  Chloroform  and   oxygen,   in  the   sitting-up   position,   with   the   head 
slightly  extended. 

(2)  Kahn's  tube. — At  one  time  this  was  used  very  frequently,  but  we  gave 
it  up  because  of  the  difficulty  of  being  certain  whether  it  was  in  the  larynx  or 
not.      The    following   two    cases   were    very    interesting   with   regard   to   this 
point : 

The  first  was  a  bone-graft  where  the  jaws  could  not  be  splinted.  I  had 
a  great  deal  of  trouble  with  the  airway,  and  as  a  last  resort  introduced  a  Kahn's 
tube.  The  head  was  lying  on  the  left  side  and  covered  up  with  towels.  It 
was  most  unlikely  that  the  tube  entered  the  larynx,  but  the  patient  at  once 
breathed  perfectly  easily  through  it. 

The  second  was  a  chin  plastic.  After  a  perfectly  quiet  anaesthetic  through 
the  Kahn's  tube,  the  patient  vomited  at  the  end  of  the  operation  before  the 
tube  had  been  removed,  and  he  vomited  entirely  through  the  tube,  nothing 
coming  into  his  mouth  past  it. 

If  the  tube  is  in  the  larynx  the  anaesthesia  is  very  good  indeed,  and  in 
these  cases  it  is  often  possible  to  reach  the  larynx  with  the  finger  and  be  certain 
that  it  is  in  position.  If  it  is  not  in  the  larynx,  it  may  still  be  serviceable,  but 
there  may  be  trouble  during  the  operation.  I  have  never  seen  shock  during 
or  following  its  use,  even  in  operations  lasting  as  long  as  four  hours. 

(3)  A  good  airway  may  also  be  obtained  by  placing  a  small  pillow  under 
the  patient's  shoulders,  extending  the  head,  and  at  the  same  time  making  traction 
on  the  tongue. 

Chloroform  and  oxygen  can  be  supplied  through  a  catheter  passed  down 


PRINCIPLES  27 

the  nose.  If  the  surgeon  objects  to  the  tongue  being  drawn  out  it  can  be  levered 
forward  by  a  sponge-holder,  the  upper  teeth  being  used  as  the  fulcrum. 

Operations  on  the  Nose. — For  short  operations  (under  two  hours)  anaesthesia 
may  be  maintained  as  follows  : 

After  induction  a  silk  stitch  is  passed  through  the  tongue  and  a  post-nasal 
plug  introduced  if  necessary.  A  very  convenient  retractor  for  the  soft  palate 
can  be  formed  by  obtaining  an  ordinary  copper  retractor  half  an  inch  wide, 
and  bending  the  last  inch  to  a  right  angle.  This  can  easily  be  slipped  behind 
the  palate,  and  takes  up  much  less  room  than  the  finger.  The  swab  is  then 
introduced  digitally,  or  with  Luc's  forceps.  A  Hewitt's  airway  is  placed  in 
the  mouth  ;  the  end  of  a  short  and  suitably  bent  metal  tube,  about  |  in.  in 
diameter,  is  placed  just  inside  the  mouth  of  the  Hewitt's  airway,  and  the  other 
end  connected  by  a  rubber  tube  to  a  Shipway's  warm  ether  apparatus.  It 
must  be  remembered  that  this  tube  must  not  be  too  long  or  the  vapour  will 
have  cooled  by  the  time  it  reaches  the  patient.  This  apparatus  is  very  econo- 
mical, and  has  the  additional  advantage  of  enabling  the  anaesthetist  to  maintain 
a  very  uniform  anaesthesia.  I  have  found  that,  using  a  mixture  of  chloroform 
and  ether,  one  compression  of  the  bulb  to  every  third  inspiration  is  sufficient 
to  keep  the  majority  of  these  men  under. 

If  a  constant  stream  of  air  or  oxygen  is  passed  through  the  apparatus 
there  is  loss  of  heat  and  waste  of  anaesthetic  during  expiration. 

In  long  operations  (over  two  hours),  such  as  rhinoplasty,  including,  as  a 
rule,  the  removal  of  a  piece  of  costal  cartilage,  we  were  at  one  time  accustomed 
to  employ  oil-ether  anaesthesia,  because  of  the  lower  incidence  of  post-anaesthetic 
vomiting  with  this  method.  This  is  especially  important  in  rib  cases  on  account 
of  the  pain. 

In  properly  selected  cases  this  is  a  very  uniform  and  safe  anaesthesia.  During 
a  personal  experience  of  over  200  cases  I  have  only  been  unduly  anxious  about 
one  patient  during  the  operation,  and  that  was  before  I  gave  up  using  hyoscine 
in  the  preliminary  hypodermic.  This  method  should  never  be  used  if  blood 
is  likely  to  enter  the  air-passages,  for  bleeding  may  continue  after  the  patient 
leaves  the  theatre,  and,  as  they  usually  take  a  long  time  to  come  round,  there 
is  grave  risk  of  blood  entering  the  trachea. 

It  should  not  be  employed  if  there  is  an  obstructed  airway — e.g.  loss  in 
lower  jaw  without  fixation,  unless  the  anaesthetist  is  prepared  to  stay  with  the 
patient  from  the  time  the  oil-ether  is  run  into  the  rectum  until  the  patient  is 
thoroughly  round  from  the  anaesthetic.  Complete  rhinoplasty  involves  little  risk 
of  post-operative  bleeding,  and  I  have  rarely  seen  any  trouble  in  these  cases. 

The  post-nasal  plug,  if  required  for  the  operation,  should  be  left  in  situ 
until  the  patient  has  recovered  from  the  anaesthetic. 


28  PLASTIC    SURGERY 

I  prefer  the  paraldehyde  mixture  ;  ether  5  oz.,  paraldehyde  2  drams,  olive 
oil  2  oz.,  but  the  paraldehyde  causes  excessive  sweating  in  some  patients.  Dose  : 
It  is  difficult  to  form  any  fixed  plan.  Some  men  go  under  quite  quickly,  whereas 
others  of  the  same  weight  require  a  great  deal  more  anaesthetic  for  induction. 
We  have  been  very  much  handicapped  by  being  unable  to  obtain  olive-oil, 
and  the  results  have  been  much  more  uniform  since  it  has  been  on  the  market 
again. 

In  cases  in  which  blood  is  not  likely  to  enter  the  airway  (except  in  cases 
where  the  jaws  are  splinted  together),  anaesthesia  may  be  maintained  by  means 
of  a  Shipway's  warm  ether  apparatus,  with  a  Hewitt's  airway  in  the  mouth,  as 
described  above  under  "  Short  Nose  Operations." 

Bone-grafts  of  the  Mandible. — As  the  jaws  are  splinted  in  the  closed-bite 
position  intra-tracheal  administration  is  out  of  the  question. 

For  a  long  time  we  gave  oil-ether  anaesthesia  for  these,  with  good  results. 
The  tongue  is  held  forward  by  the  splinted  lower  jaw  and  does  not  fall  back. 
It  is  better  to  ensure  free  nose  breathing  by  introducing  a  nasal  tube  Additional 
anaesthesia  may  be  given  either  through  this  or  through  a  bent  metal  tube  placed 
in  the  mouth.  As  an  alternative,  a  general  anaesthetic  may  be  given  through 
a  nasal  tube  as  described  above,  under  "  Operations  involving  the  Mouth." 
During  the  last  six  months  we  have  given  up  oil-ether  anaesthesia  for  these  cases 
and  have  employed  chloroform  and  oxygen  through  a  nasal  tube  with  satisfactory 
results,  and  I  think  it  is  to  be  preferred,  both  on  account  of  the  lessened  risk 
of  pneumonia,  and  the  quick  recovery  from  the  anaesthetic. 

In  this  class  of  surgery  there  should  be  more  than  usual  co-operation  between 
the  surgeon  and  the  anaesthetist,  both  in  regard  to  watchfulness  over  the  patient's 
condition  and  in  manipulations  involving  the  airway. 

R.  WADE. 

OPERATION 

The  general  technique  of  a  plastic  operation  differs  slightly  from  that  used 
in  general  surgery,  in  that  the  question  of  the  ultimate  appearance  of  the  area 
of  operation  occupies  a  much  more  important  place.  The  slightest  insult  to 
the  skin  of  the  face  is  in  some  subjects  visibly  recorded  in  scar  tissue,  especially 
where  the  blood-supply  is  poor  from  any  reason,  such  as  tension  or  the  presence 
of  scar  tissue ;  and  it  is  therefore  bad  practice  to  use  tissue  forceps  upon  the 
skin  edges,  the  grip  being  properly  taken  on  the  deep  surface.  The  production 
of  an  invisible  scar  is  a  question  constantly  exercising  the  mind  of  the  plastic 
surgeon. 

A  few  points  are  given  below  descriptive  of  the  author's  usual  practice 
with  regard  to  general  technique  which  may  prove  of  interest. 


PRINCIPLES  29 

The  skin  of  the  patient  is  usually  prepared  at  the  time  of  operation  by  firm 
wiping  of  the  parts  with  an  ether  swab.  This  removes  saprophytes  on  the  surface 
without  damaging  the  epithelium.  This  is  usually  followed  by  a  light  coating 
of  iodine,  applied  once  only.  In  cases  where  the  epithelium  is  tender,  as  in 
burnt  cases,  the  ether  is  followed  by  methylated  spirit,  the  iodine  being  omitted. 
It  is  also  possible  that  iodine  is  an  unsuitable  preparation  for  skins  that  have 
previously  been  the  seat  of  erysipelas.  Similarly,  in  young  subjects  and  in 
women  where  the  epithelium  is  delicate,  the  iodine  is  omitted.  The  same 
holds  good  in  the  preparation  of  areas  from  which  skin-grafts,  either  Thiersch 
or  Wolfe,  are  to  be  removed.  For  Thiersch  grafts,  very  vigorous  rubbing  with 
ether  is  practised  until  the  whole  area  glows. 

The  general  care  of  the  patient  with  regard  to  fatigue,  shock,  and  haemorrhage 
must  be  borne  in  mind,  just  as  in  other  branches  of  surgery.  The  treatment, 
actual  and  preventive,  has  no  features  peculiar  to  this  branch  of  surgery.  A 
special  note  of  warning,  however,  will  not  be  out  of  place  in  regard  to  the  in- 
halation of  blood  and  mucus,  which  will  further  decrease  an  airway  often  already 
insufficient,  and  will  greatly  add  to  the  patient's  fatigue  in  these  lengthy  opera- 
tions. The  amount  of  shock  produced  by  an  operation  depends,  among  other 
things,  upon  the  area  of  disturbed  skin  surface.  This  is  particularly  noticeable 
when  large  chest  skin-flaps  are  used  for  the  face. 

Needless  to  say,  the  general  and  local  condition  must  be  the  best  possible 
before  a  major  plastic  operation  can  be  undertaken.  The  original  wound 
must  have  healed  soundly,  the  condition  of  the  upper  respiratory  passages  and 
accessory  sinuses  must  be  above  suspicion,  and  the  skin  must  be  free  from  pimples, 
acne  pustules,  and  the  like.  In  many  cases  certain  preliminaries  will  have  been 
completed,  such  as  the  excision  of  exuberant  scars,  or  non-operative  treatment 
to  soften  keloidal  tissue  and  improve  the  blood-supply. 

Stages. — Most  of  our  operations  consist  of  two  or  more  stages.  The  use 
of  bridge-flaps  necessitates  a  second  operation  for  the  return  of  the  pedicle, 
but  this  does  not  always  need  a  general  anaesthetic.  The  pedicle  is  returned 
not  earlier  than  ten  days  in  most  cases,  and  it  is  of  advantage  largely  to  increase 
this  interval  where  the  blood-supply  of  the  receiving  bed  is  dubious.  The 
returned  pedicle  covers  most  of  the  bare  area  from  which  the  flap  was  taken, 
and  the  remainder  is  covered  either  by  undercutting  and  advancing  the  margins, 
or  by  a  Wolfe  or  whole-thickness  graft.  The  graft,  after  being  sutured,  should 
be  pressed  firmly  into  place  and  held  there  by  a  pad  of  gauze  or  a  Stent  mould 
firmly  bandaged  to  the  head.  The  most  frequent  cause  of  failure  of  a  Wolfe 
graft  is  lack  of  pressure  firm  enough  to  ensure  complete  apposition.  Apart 
from  the  return  of  pedicles,  our  operations  are  frequently  designed  in  stages  ; 
for  instance,  in  rhinoplasty  the  normal  portions  of  the  tip  and  alse  have  frequently 


30  PLASTIC    SURGERY 

to  be  released  from  scar  tissue  and  restored  to  their  normal  positions  at  a  stage 
prior  to  the  remaking.  At  this  stage  also  the  blood-supply  of  the  prospective 
inturned  flaps  is  secured  by  attaching  their  future  base  to  the  rich  blood-supply 
of  the  nasal  mucosa.  Similarly,  in  large  facial  replacements  for  burns,  the 
blood-supply  of  the  flaps  is  rendered  more  secure  by  the  preliminary  tubing 
of  the  pedicles.  Countless  other  examples  of  the  necessity  of  dividing  the 
restoration  into  stages  will  spring  to  the  mind  of  the  reader. 

The  simplest  operation  in  plastic  work  is  the  excision  of  scars.     This  is 
important,  not  only  from  the  cosmetic  point  of  view.     Apart  from  actual  loss, 


1.  Depressed  scar. 


2.  Incisions  for  excision  of  scar 
and  delimitation  of  fat  flap. 


3.  Fat  flap  swinging.  4.  Flap  fixed  under  new  scar. 

A.  FAT  FLAP  BASED  ON  DEEP  FASCIA. 


JL    1 


I 


1.  Depressed  scar.  2.  Incisions.  3.  Suture. 

B.  FAT  FLAP  BASED  ON  THE  SKIN. 
FlO.  9. — Showing  use  of  subcutaneous  fat  flaps.     (Sectional  view.) 

no  factor  so  impedes  function  as  does  scar  tissue,  whether  by  hampering  mobility 
or  by  constriction  of  tubular  organs,  such  as  blood  vessels  and  ducts. 
The  general  aims  in  scar  excision  are  : 

1.  Liberation  of  fettered  tissue. 

2.  Restoration  of  contour. 

In  either  case  it  is  essential  that  all  the  scar  be  excised.  It  is  remarkable 
to  what  extent  a  deformity  will  recur  if  only  a  small  amount  of  scar  escapes. 

In  unfavourable  subjects  it  may  be  that  the  scar  must  be  excised  a  second 
or  even  a  third  time  before  a  presentable  appearance  is  effected. 

The  restoration  of  contour  is  aided  by  the  subcutaneous  rolling  in  of  fat- 
flaps,  as  indicated  in  the  accompanying  diagrams.  In  most  cases  the  flap  is 


PRINCIPLES 


31 


based  on  the  deep  fascia  (fig.  9  A  :  1  to  4),  the  skin  being  undercut  till  the  desired 
area  of  fat  is  exposed,  after  which  the  knife  is  carried  deeper  till  the  flap  can  be 
drawn  across  and  sutured  in  its  new  position.  In  another  method  (Aymard) 
the  flap  is  based  upon  the  overlying  skin.  This  is  more  difficult  of  execution, 
as  the  knife  is  invisible  during  the  delimitation  of  the  flap,  but  it  is  the  method 
of  choice  on  occasion,  especially  in  the  malar  region. 

Suture. — The  insertion  of  sutures  occupies  about  half  the  time  taken  by 
one  of  these  long  operations.     Sewing  up  after  a  total  rhinoplasty  takes  almost  .1, 
one  hour  even  in  experienced  hands  :    so  that  dexterity  and  smooth  technique  9§ 


Fio.   10. — Author's  instrument. 


in  this  particular  are  of  outstanding  importance  for  the  sake  of  the  patient. 
The  "  No  Touch  "  technique  is  fortunately  compatible  with  this  desideratum  ; 
it  is  found  that,  with  practice,  stitches  can  be  tied  very  rapidly  with  forceps, 
especially  with  the  author's  instrument  depicted  above.  This  instrument  also 
embodies  the  property  of  scissors,  and  further  saves  time  by  allowing  the  surgeon 
to  cut  his  own  sutures. 

The  material  usually  employed  for  the  apposing  layer  is  horsehair  ;    its 
elasticity  is  of  great  importance  in  allowing  a  nice  adjustment  of  the  edges, 


32 


PLASTIC    SURGERY 


especially  when  employed  in  continuous  suture,  as  is  very  often  the  case.  In- 
terrupted sutures  are  first  inserted  at  corners  and  other  guiding  points,  and  the 
continuous  suture  is  carried  right  past  them.  A  trial  is  now  being  made  of 
"  Japanese  Silkworm  Gut,"  a  material  of  great  elasticity,  the  strength  of  which, 
in  proportion  to  its  calibre,  is  even  greater  than  that  of  horsehair.  Retaining 
sutures  are  of  silkworm  gut. 

The  use  of  subcuticular  sutures  for  the  closure  of  facial  wounds  would  at 
first  sight  seem  to  be  ideal ;  and,  under  certain  conditions,  this  is  the  case.  A 
long,  straight  incision,  all  portions  of  which  are  in  the  same  plane,  is  best  closed 
by  this  means.  But  where  an  incision  is  irregular  or  passes  over  an  alteration 
of  contour,  the  avoidance  of  "  bunching  "  is  so  difficult  with  a  subcuticular 
suture  that  a  good  scar  is  more  likely  to  result  by  other  means. 

Subcutaneous  sutures  are  of  great  value  as  retaining  sutures.  The  author 
uses  a  modification  of  the  "  near-far  far-near  "  suture  to  subserve  the  double 
purpose  of  retention  and  apposition  as  indicated  in  fig.  11,  which  prevents  in- 
version of  the  edges. 


SECTIOMflL       VIE1W 


THt    SUTURE 
IN      POSITION 


FIG.   11. — Subcutaneous  near-far  far-near  suture. 


The  material  employed  for  subcuticular  apposing  sutures  is  usually  horse- 
hair. Catgut  is  found  to  produce  a  heaped-up  edge,  and  linen  thread  has,  on 
more  than  one  occasion,  proved  itself  to  be  an  irritant. 

Catgut  is  the  material  of  choice  for  subcutaneous  retention  sutures,  chromic 
gut  not  being  well  tolerated  in  the  face. 

Invisible  Scars.— The  author  has  devoted  much  time  and  thought  to  the 


PRINCIPLES  33 

production  of  the  optimum  scar.  It  actually  happens  on  occasion  that  a  facial 
scar  is  for  practical  purposes  invisible,  but  one  must  admit  that  the  factors  for 
ensuring  such  a  desirable  result  are  not  always  to  hand. 

The  factors  necessary  for  the  production  of  the  optimum  scar  are  : 

(1)  Asepsis. 

(2)  Avoidance  of  tension  on  the  apposing  sutures. 

(3)  Perfect  apposition  of  the  skin  edges. 

(4)  An  often  unknown  personal  factor  in  the  patient. 

(5)  Early  removal  of  sutures. 

The  avoidance  of  tension  on  the  edges  is  found  to  be  a  factor  of  extreme 
importance  :  one  often  sees  a  transposed  flap,  the  scar  delimiting  one  edge  of 
Avhich  is  clearly  visible,  while  that  along  the  other  edge  is  almost  invisible,  the 
difference  being  due  to  the  fact  that  there  is  inevitably  more  tension  on  the  edge 
along  the  long  or  convex  side.  To  avoid  tension  on  the  edges  it  is  customary 
to  insert  deep  retaining  sutures  wide  of  the  incision,  the  ends  being,  if  necessary, 
guarded  by  buttons  to  distribute  the  pressure.  The  apposing  sutures  should 
be  inserted  very  close  to  the  edges,  and  may  be  at  very  close  interval  if  that 
is  thought  necessary  to  ensure  a  critical  closure.  Apposition  is  occasionally 
assisted  by  the  insertion  of  a  few  everting  mattress  sutures  about  3  mm.  from 
the  edge.  With  a  view  to  ultimate  invisibility  of  scar  some  surgeons  make 
their  incisions  with  the  plane  of  the  blade  at  an  oblique  angle  with  the  surface, 
so  that  Avhen  the  wound  is  closed  there  is  a  slight  overlapping  of  one  edge  by 
the  other. 


VLR.TICflL     INCISION 


OBLIQUE. 

FIG.  12. — Incisions. 

The  author  has  not  found  that  this  method  on  the  whole  leads  to  a  more 
perfect  scar. 

It  is  found  that  invisible  scars  more  often  occur  in  patients  whose  skins 
are  ruddy  and  beset  with  small  venules.  Skin-flaps  on  such  subjects  are  wont 
to  acquire  a  florid  habit,  and  their  edges  soon  fade  into  their  surroundings,  the 
scars  becoming  permeated  with  the  tiny  vessels. 

Dressings. — Dressings  are  but  seldom  required  upon  the  face.     Where  a 

3 


34  PLASTIC    SURGERY 

wound  has  been  closed  with  drainage  an  appropriate  covering  is  naturally  applied, 
and  it  is  customary  in  the  case  of  grafts  to  provide  some  means  of  maintaining 
firm  apposition  ;  but  for  the  most  part  the  face  is  left  exposed  to  the  air.  Where 
it  has  been  necessary  to  use  a  flap  of  precarious  viability,  hot  saline  packs  are 
applied  at  the  close  of  the  operation  and  are  renewed  two-hourly,  with  excellent 
results. 

AFTER-TREATMENT 

Apposing  sutures  are  removed  on  the  third  or  fourth  day,  retaining  sutures 
being  left  till  their  function  is  fulfilled.  Thus,  it  is  the  author's  custom  at  the 
conclusion  of  a  rhinoplasty,  to  insert  one  or  more  horsehair  stitches  transversely 
through  the  new  nose,  and  tie  them  so  as  to  produce  a  narrowing  of  the  organ 
at  certain  spots.  These  are  left  till  they  have  caused  a  certain  amount  of  in- 
flammation, so  that  the  scar-tissue  which  ensues  will  take  over  their  function 
permanently. 

Massage  is  of  great  use  in  dispersing  the  oedema  which  often  arises  as  a 
temporary  disability  in  newly  made  flaps,  and  is  indicated  as  a  routine  measure 
for  assisting  in  the  restoration  of  function. 

The  closest  watch  is  maintained  during  the  first  forty-eight  hours  upon  the 
site  of  operation,  especially  where  a  new  or  doubtful  flap  has  been  employed. 
Even  in  well-tried  flaps  cedema  may  occur,  and  lead  to  disaster  unless  promptly 
dealt  with. 

Electrical  treatment  in  the  form  of  vibro-massage  for  bone  lesions,  diathermy, 
ionisation,  X  and  other  rays,  is  part  of  the  routine  after-treatment,  as  in  other 
branches  of  restorative  surgery. 

A  trial  is  being  made  at  present  of  the  application  of  a  rhythmic  sinusoidal 
current  as  an  aid  to  osteogenesis  in  mandibular  bone-grafts.  (Barclay.) 

Early  active  movements  are  encouraged,  generally  speaking ;  and  this 
principle  is  applied  to  mandibular  bone  grafts  where  the  gap  is  inconsiderable. 

In  conclusion,  it  may  be  said  that  Time  is  the  plastic  surgeon's  greatest 
ally,  and  at  the  same  time  his  most  trenchant  critic. 


REPAIR    OF  THE   CHEEK 


CHAPTER  II 
REPAIR  OF  THE  CHEEK 

IN  discussing  in  detail  the  experience  in  the  repair  of  the  various  sections, 
it  is  not  possible  to  confine  each  case  and  its  method  of  repair  within 
exact  categories ;  but  as  far  as  possible  I  have  divided  the  face  into  regions, 
and  each  region  into  groups,  as  judged  by  the  extent  of  the  destruction.  In 
each  group  the  methods  of  repair  used  are  set  forth  and  the  results  criticised, 
while  examples  of  cases  and  methods  are  interspersed  in  the  reading  matter, 
so  that  reasons  for  many  statements  may  be  supported  by  illustrations  of 
actual  cases.  Many  of  these  cheek  injuries  secondarily  involve  the  lower  eyelid, 
the  nose,  or  the  mouth ;  but  the  following  cases,  though  thus  complicated,  have 
their  main  interest  centred  in  the  cheek  repair.  Owing,  however,  to  the  obvious 
overlapping  of  the  injury  from  one  to  other  regions,  cross  references  will  fre- 
quently be  made  to  the  part  of  the  book  where  the  illustration  is  to  be  found. 
Thus,  Case  70,  in  the  chapter  on  noses,  shows  a  very  severe  cheek  injury,  but 
as  the  interest  of  the  repair,  to  my  mind,  is  centred  in  the  smaller  nasal  part 
of  the  injury,  it  is  not  separately  described  in  the  present  chapter. 

The  cheek  is  an  area  of  plastic  surgery  which  lends  itself  to  good  results. 
The  lining  membrane  is  not  usually  a  stumbling-block,  as  in  lip  and  nose  work. 
The  supporting  structure,  when  not  supplied  by  a  dental  prosthesis,  is  found  in 
a  bone  graft  for  the  mandible,  cartilage  for  the  superior  maxilla,  and  muscle  or 
cartilage  for  the  malar-zygomatic  prominence.  The  skin  covering,  when  not 
available  locally,  is  made  good  by  flaps  from  the  whole  neck  area  or  from  the 
temporal  region. 

I  have  arbitrarily  divided  this  region  into  : 

(a)  Depressed  scars. 
(6)  Loss  of  soft  tissues  only. 

(c)  Loss  of  soft  tissues  with  loss  of  bony   substructure  which  may 
be  deficient  in  the  following  situations  : 

(1)  Malar  Prominence. 

(2)  Superior  Maxilla — Alveolus,  Antral  Wall,  Infra-orbital 

Plate. 

(3)  Mandible. 

(a)  DEPRESSED   SCARS 

Depressed  scars  may  be  defined  as  those  associated  with  such  small  losses 
of  tissue  that  the  majority  of  them  may  be  repaired  by  excision  of  the  scar, 
under-cutting  the  skin  and  approximation,  without  the  necessity  of  cutting 
flaps. 


37 


38  PLASTIC   SURGERY 

They  are  usually  the  result  of  the  exit  of  a  bullet,  of  the  glancing  blow  of 
a  fragment,  or  of  the  entrance  of  a  small  shell  or  bomb  fragment.     The  scar 
produced   by  an   exit   wound  is   stellate,  while   that   of  an   entrance  wound, 
though   it   may  be   irregular,    is   usually   concentrated   in   the   middle   of  the 
depression.      Of  the  two  kinds,  the  radiating  scar  is  the   more   difficult   of 
elimination.     My  usual  practice  carries  me  into  a  somewhat  tedious  individual 
excision  of  each  scar  in  addition  to  the  central  core.     Frequently,  however,  a 
compromise   is   carried   out   by  the   removal   of  the   more   important   of  the 
radiations,  leaving  the  lesser  to  time  and  the   end   of  the   war:    a   method 
which  hastens  the  man's  return  to  duty  and  conserves  the  energies  and  time 
of  the  theatre   staff  for    more   important  work.     Not  only  the   scar  but  the 
depression  should  be  removed,  and  for  this  purpose  it  is  of  great  advantage 
to  roll  in  local  fat  and  muscle  flaps  from  the  surrounding  area  under  the  new 
line  of  union,  a  practice  which  I  have  carried  out  from  the  beginning,  and 
which  is  described  in  detail  in  Principles. 

Apart  from  the  filling  of  the  depressions,  which  is  the  most  essential  part 
of  the  treatment  of  these  scars,  the  success  of  the  procedure  is  to  be  judged 
by  the  character  and  amount  of  the  residual  operation  scar. 

If  a  happy  result  is  desired,  considerable  thought  and  care  must  be  bestowed 
on  the  details  of  the  skin  closure.     The  incision  must  be  clear  of  the  cicatrix, 
not  only  of  the  visible  but  also  of  the  palpable  portion.     Horsehair,  fine  and 
elastic  strands  being  chosen,  gives  the  best  result,  as  no  other  suture  material 
presents  this  elasticity.     Stitch-marks  are  avoided  by  taking  out  the  stitches 
on  the  second,  third,  or  fourth  day,  according  to  the  tension,  and  by  taking  up 
the  tension  by  deep  catgut  sutures.     If  eversion  of  both  edges  is  required  a 
mattress  suture  is  employed,  if  of  one  edge  only,  the  semi-subcuticular  mattress, 
while  between  these  everting  sutures  the  simple  or  the  four- twist  knot  is  indicated. 
The  various  little  flaps  should  be  brought  together  and  deep  catgut  inserted, 
so  that  there  be  no  tension  on  the  horsehair  edge-to-edge  sutures.     Frequently 
difficulties  arise  at  this  stage,  and  one  is  confronted  with  the  necessity  to  make 
a  decision  as  to  whether  the  parts  can  be  pulled  together  without  undue  strain, 
or  whether  a  flap  is  necessary  to  complete.      It  is  usually  easy  to  make,  by 
further  incision,  one  of  the  little  flaps  into  a  bigger  one,  and  so  overcome  the 
difficulty ;   and  I  feel  that  a  guiding  principle  which  stands  the  tests  in  most 
cases  is  that   "  when   in   doubt,   cut  a   small   flap."      The   fine   edge  sutures 
should  receive  minute  attention,  so  that  the  very  edges  of  the  cut  skin  are 
apposed.     Round  the  centre  of  the  depression,  where  the  apices  of  the  stellate 
flaps   meet,    suturing  becomes  difficult.     Frequently  it  is  better  to  put  in   a 
modified  purse-string  or  a  mattress  method  involving  more  than  one  flap,  as 
there  is  no  room  for  many  fine  stitches. 


REPAIR    OF    THE    CHEEK 


39 


FIG.  13. — A  few  days  subsequent  to  a  double  shell- 
wound. 


Fio.  14. — After  the  plastic  on  the  cheek  and  simple 
healing  of  the  chin.  Note  the  restoration  of  cheek 
contour,  but  the  indifferent  operation  scar. 


CASE   83 

Illustrated  in  the  accompanying  figs.,  requires  little  elaboration.  He  was  wounded 
by  shell,  on  23.7.16,  in  two  separate  places,  each  wound  being  of  an  explosive 
nature.  The  wound  of  the  chin,  as  shown  in  fig.  13,  healed  of  its  own  accord, 
without  any  operation  (see  fig.  14),  while  the  wound  of  the  left  antrum  healed  with 
a  large  depressed  scar  which  was  treated  by  excision  of  the  scar  tissue,  and  by 
rolling  in  fat-flaps,  as  described  in  the  chapter  on  Principles.  It  will  be  noted  that 
the  patient's  left  eye  was  enucleated  in  the  early  stage  by  the  ophthalmic  specialist 
on  account  of  the  injuries  it  had  received.  The  scar  tissue  was  widely  excised 
under  general  anaesthesia,  and  local  fat-flaps  were  turned  in  to  fill  up  the  missing 
contour  and  sutured  with  catgut,  the  skin  being  united  with  interrupted  horsehair 
stitches.  The  photographs,  taken  on  the  patient's  discharge  from  hospital,  show  the 
result  of  this  simple  procedure. 

In  criticising  this  result,  it  appears  obvious  to  me  that  the  whole  scar  was  not  removed, 
and  that,  had  palpation  been  made,  the  edges  of  the  wound  would  have  felt  hard  and  un- 
yielding. The  consequence  of  leaving  this  indurated  subcuticular  area  is  that  the  edge 
has  remained  heaped  up  in  places,  and  does  not  lie  as  flat  as  it  would  otherwise  have  done. 
The  condition  is,  of  course,  eminently  suitable  for  further  treatment  in  the  way  of  re-excision, 
but  such  would  probably  have  been  unnecessary  had  the  above-mentioned  precautions 
been  taken  in  the  first  instance.  However,  even  when  the  whole  scar  tissue  is  successfully 
excised,  the  first  operation  scar  is  not  usually  as  good  as  when  a  second  or  even  a  third 
linear  excision  is  undertaken,  suitable  intervals  being  allowed  to  elapse  between  operations. 


lo  PLASTIC   SURGERY 


CASE  37 

This  officer  received  a  long,  gashing  wound  of  the  left  cheek,  which  is  well  illustrated. 
At  its  maximum  depth,  it  penetrated  to  the  mouth  (buccal  fistula),  and,  during  the  course 
of  the  missile,  the  mandible  was  fractured  with  loss  of  bone,  mainly  alveolar.  Two  pointed 
ends  of  the  lower  border  of  the  bone  remained  in  close  proximity  in  the  bottom  of  the  wound, 
and  at  the  later  operation  scar  tissue  was  excised  between  these  points,  which  were  them- 
selves freshened.  Combined  with  dental  splinting  and  necessary  extractions,  this  freshening 
resulted  in  bony  union,  so  that  the  injury  may  be  classed  as  one  without  loss  of  bony  contour. 

The  healed  condition  in  a  case  like  this  is  merely  one  of  a  very  large  depressed  scar. 
The  good  result  obtained  was  due,  I  think,  to  the  use  of  fat  flaps,  as  previously  explained 
and  as  the  diagram  represents.  On  this  occasion  they  were  rolled  in  towards  the  depression, 
having  their  blood  supply  from  the  deep  tissues  :  the  skin,  thus  undercut,  was  drawn  over 
the  fatty  prominence  and  accurately  sutured.  The  skin  edges  were  cut  markedly  on  the 
slant  or  bevel,  and  the  stitch  used  was  the  semi-subcutaneous  horsehair  mattress  suture 
(vide  p.  33),  reinforced  by  a  few  edge-to-cdge  stitches.  The  upper  part  of  the  scar  was 
invisible  as  such  before  this  patient  left  hospital,  but  there  was  still  a  slight  depression 
which  marked  its  site. 

The  final  history  of  this  gallant  officer  from  the  Dominions  is  pathetic.  Soon  after 
being  posted  back  to  duty  he  volunteered  for  foreign  service  again,  was  shot  through  the 
knee-joint,  and  died  of  wounds  in  the  same  Casualty  Clearing  Station  as  that  which  received 
him  when  his  face  was  wounded. 


REPAIR    OF    THE    CHEEK 


41 


i  g. — On  admission  10  days  after  wound.     Lower 
facial  paralysis. 


Fid.  1G  represents^fat  flaps  rolled  in  towards 
the  centre  of  the  depression. 


FIG.  1 7. — Result. — Note :  the  smudge  beneath  the 
chin  was  a  result  of  shaving,  and  has  been  removed  on 
the  print.  There  was  no  appreciable  facial  paralysis 
at  this  stage. 


42  PLASTIC   SURGERY 

Literally  one  might  give  hundreds  of  examples  of  these  scars  and  of  the 
results  of  their  excision,  and  I  need  only  here  refer  to  my  remarks  in  Chapter 
I,  p.  33,  where  I  have  discussed  the  production  of  invisible  wound  scars. 


(6)    WOUNDS  OF   THE  CHEEK,   WITH   LOSS   OF   SOFT 

TISSUE  ONLY 

Here,  again,  the  definition  of  this  class  can  be  no  more  than  arbitrary, 
as  some  of  the  examples  are  merely  extra  large  depressed  scars,  while  others 
include  in  their  lesion  a  loss  of  bone.  They  may  be  described  as  cases 
requiring  the  provision  of  flaps,  but  not  including  any  serious  operation  for 
the  restoration  of  the  lost  bone. 

CASE  27 

Gunner  P.  was  wounded  22.7.16,  and  admitted  to  me  on  10.12.16,  in  the  healed 
condition,  as  shown  in  fig.  18.  There  was  a  large  loss  of  soft  tissue  involving  the 
left  corner  of  the  mouth  and  the  region  of  the  cheek  extending  outwards  from  this 
corner.  The  wound  had  healed  by  scar  tissue,  and  besides  considerable  deformity, 
there  was  much  loss  of  function  through  contraction.  The  first  operation  I  per- 
formed on  10 . 1 . 17  was  a  complete  failure,  due  entirely  to  a  haematoma  which 
formed  under  the  flap.  The  flap  had  to  be  raised  in  order  to  evacuate  the  blood : 
none  of  the  stitches  held.  The  condition  when  healed,  after  this  unfortunate  occur- 
rence, was  practically  the  same  as  on  admission,  but 
with  one  additional  scar.  On  5.3.17,  the  con- 
dition had  been  healed  so  long  that  a  second 
operation  was  judged  to  be  possible.  On  this 
occasion  a  large  thick  musculo-cutaneous  flap,  in 
breadth  about  1  £  in.,  was  taken  from  the  left  naso- 
labial  and  left  infra-orbital  regions  and  swung  down 
towards  the  corner  of  the  mouth  (where,  after 
the  excision  of  the  scar,  there  was  a  large  deficiency 
of  skin  and  muscle),  as  shown  in  the  diagram, 
fig.  20.  The  scar  tissue  excised  at  the  corner 
of  the  mouth  included  about  a  third  of  the  upper 
lip,  and  did  not  penetrate  farther  than  the  deep 
surface  of  the  mucous  membrane  of  the  mouth. 
On  attempting  to  fit  the  flap  in  at  the  corner  of 
the  mouth,  I  realised  that  it  had  to  be  split,  the 
larger  portion  going  to  the  upper  lip  and  the 
smaller  to  the  lower. 

Another  interesting  point  in  this  case  is  to 
be  observed  in  the  fact  that  a  large  flap  can  be 
taken  from  this  region  without  causing  serious 
secondary  deformity.  The  result  of  this  operation 
was  very  satisfactory,  and  the  value  of  a  split 
flap  at  the  corner  of  the  mouth  is  established 
by  this  case  and  by  Case  220  (page  56).  This 
-Actual  loss  greater  than  apparent.  patient  was  discharged  from  hospital  on  1-1.5. 17. 


REPAIR    OF    THE    CHEEK 


43 


Fio.  19. — Flap. 


FIG.  20. — Suture.     Note  splitting  of  flop  to  form 
angle  of  mouth. 


FIG.  21. — After  plastic.     Lips  apart,  lower  scars 
not  treated. 


FIG.  22. — After  plastic.     Lips  closed.     Split  flap 
to  form  corner  of  mouth. 


1 1 


PLASTIC   SURGERY 


CASE   292 

Fig.  23,  of  this  case  represents  the  condition  of  Sergeant  15.  on  admission  into 
this  department  on  15.6.17.  IK-  was  wounded  on  10.9.10.  Previous  notes  and 
photographs  are  not  available.  lint  it  is  obvious  that  he  had  a  shell  wound  pene- 
trating the  left  antnmi,  with  the  loss  of  infra-orbital  plate,  and  a  large  depressed 
scar  on  cheek.  The  sear  was  excised  on  14.7.17,  under  general  anaesthesia,  and  a 
large  fat  graft,  measuring  .'5  in.  by  2|  in.  by  ?  in.  thick  was  taken  from  left  buttock 
and  fixed"  in  the  depression  by  "catgut.  Everything  proceeded  normally  until  the 
fourteenth  day,  when  first  fat  necrosis,  and  subsequently  suppuration  occurred. 
necessitating  drainage  from  the  centre  and  from  the  dependent  portion  of  the  sear. 
This  suppuration  continued  for  about  four  weeks.  His  condition  when  the  suppuration 
ceased  is  shown  in  fig.  24.  I  illustrate  this  case  to  show  that,  although  a  fat  graft 


Fia.  23. — On  admission — healed. 


FIG.  24. — Left  eye — enucleated.     Fat  graft  to  cheek. 


may  not  succeed  in  toto,  yet,  even  if  it  suppurates,  very  considerable  improvement 
in  the  contour  is  invariably  produced.  In  order  to  complete  this  case,  it  appeared 
advisable  to  implant  a  cartilaginous  plate  to  take  the  place  of  the  lost  infra-orbital 
margin. 

At  the  same  time,  it.  was  decided  to  utilise  a  piece  of  cartilage  for  a  prosthesis 
of  the  eye  socket,  which  was  of  a  very  shrunken  character. 

Two  operations  were  therefore  carried  out  at  the  same  time  on  10.9.17.  An 
incision  was  made  parallel  to  the  lower  lid  and  over  the  infra-orbital  margin,  and  the 
skin  undermined  in  the  neighbourhood.  A  piece  of  cartilage,  composed  of  a  portion 
of  two  adjacent  rib  cartilages,  was  removed  for  me  by  Captain  H.  Montgomery, 
H.A..M.C..  IVoni  this  patient's  right  thorax,  the  attachment  between  the  two  rib 
earl  Mages  being  left  undisturbed.  It  was  pared  with  the  knife  until  it  was  of  such  a  shape 
that  the  (•(  ml  our  was  accurately  reconstructed,  placed  in  position,  and  the  skin  reunited 
over  it  with  siibcut  icular  horsehair.  The  sternal  end  of  the  7th  cartilage  was  then  taken,  in 


REPAIR    OF    THE    CHEEK 


45 


its  whole  thickness,  and  shaped  into  a  cup  and  ball,  as  described  in  the  chapter  on  Eye 
Plastics,  p.  339.  These  two  pieces  of  cartilage  were  inserted  into  the  depths  of  tin- 
eye-socket  through  an  horizontal  incision  made  in  the  conjunctiva.  The  two  wounds 
healed  by  primary  intention,  and,  after  the  fitting  of  an  artificial  eye,  the  result  was 
very  satisfactory.  Diagrams  illustrating  these  later  operations  are  appended. 


FIG.  25. — After  cartilage  grafts  to  socket  and  cheek. 
Artificial  eye  fitted. 


Flo.  26.-— Ditto.     Same  stage< 


Sec  tion 


Cartilage 
,  Prosthesis, 

of  L.  Socket 

\X7CM  Costal 
N  8 ^[Cartilage 


FIG.  27. — Diagram  of  cartilage  implants. 


46 


PLASTIC   SURGERY 


CASE  73 

Represents  a  type  of  case  in  which  there  was  partial  loss  of  the  malar  bone  and 
fracture  of  the  lower  jaw.  The  deformity  is  not  one  which  calls  for  definite  recon- 
stitution  of  the  bony  framework. 

Private  C.  was  wounded  on  1.7.16,  and  his  condition  on  admission  on  6. 7. 1C 
is  shown  in  fig.  30,  the  result  of  a  severe  shell- wound.  On  29.11.16  Lieutenant 
C.  B.  Tudchope,  R.A.M.C.,  performed  an  operation.  The  large  scar,  extending  from 
the  outer  orbital  angle  to  half  an  inch  below  the  lobule  of  the  left  ear,  was 
excised.  The  fibrous  tissue  was  so  thick  that  the  dissection  led  down  to  the  remains 
of  the  malar  bone  and  horizontal  ramus  of  mandible.  This  dissection  completely  freed 
the  lobule  of  the  ear.  In  order  to  build  up  the  contour,  local  fat-flaps  were  turned 
in  and  sutured  with  catgut  but,  owing  to  this  being  insufficient,  a  small  free  fat-flap 
from  the  buttock  was  implanted.  The  wound  was  closed  by  relaxation  and  horse- 
hair sutures,  without  drainage,  the  lobule  of  the  ear  being  adjusted  to  position. 
Moderate  suppuration  of  this  fat-graft  occurred,  but  the  condition  shortly  before 
discharge  was  as  shown  in  fig.  31.  The  fracture  of  the  lower  jaw  necessitated  the 
patient's  stay  in  hospital  for  a  longer  period,  and  he  was  not  discharged  until  21.4.17. 
It  is  obvious  that  this  wound  involved  the  destruction  of  branches  of  the  temporo- 
facial  nerve. 


.- 


Fio.  28. — "  Natural  "  flaps  made  by  excision  of  scar. 


Fio.  30. — Five  days  after  wound. 


Fia.  31. — Result  plastic.     Note  :  upper  facial  paralysis 
only. 


REPAIR    OF    THE    CHEEK 


47 


CASE   33 

In  this  case  the  wound  of  the  left  cheek  was  complicated  by  loss  of  bone  in  the  upper 
jaw.  The  wound  also  extended  from  the  left  corner  of  the  mouth  and  opened  widely  into 
the  buccal  cavity.  Unfortunately  I  have  no  record  of  the  healed  condition,  and  in  view 
of  one's  experience,  this  spectacular  result  is  to  be,  to  a  certain  extent,  discounted.  The 
first  operation  (27.10.16)  was  performed  three  months  after  his  shell- wound.  The  aim 
was  to  reform  the  corner  of  the  mouth,  adjacent  portions  of  both  lips,  and  a  considerable 
amount  of  check  ;  and  a  large  dense  scar  had  to  be  excised.  The  mucosa  was  carefully 
dissected  and  sewn  to  reform  the  buccal  lining  and  to  complete  the  upper  lip.  My  notes 
read  that  there  was  much  less  loss  of  tissue  than  was  expected. 

The  result  was  gratifying,  but  as  a  considerable  amount  of  scar  tissue  remained  on  the 
edges  after  excision  of  the  main  part  of  the  scar,  the  line  of  union  was  not  expected  to  be 
perfect.  A  particular  twist  of  a  mucous  flap  satisfactorily  formed  the  corner  of  the  mouth, 
and  the  wound  healed  well. 

Two  months  later,  a  second  operation  was  performed  :  the  scar  was  excised,  and  fat 
flaps  sutured  beneath  the  line  of  incision,  which  was  closed  with  horsehair  sutures.  In 
order  to  complete  the  case  from  a  dental  point  of  view,  an  extensive  incision  was  made 
along  the  left  alveolar  border  of  the  maxilla  and  a  vulcanite  plate  inserted,  held  in 
position  by  elastic  traction  from  a  dental  splint. 

A  denture  was  then  adapted  to  the  upper  jaw,  but  I  heard  later  from  the  patient  that 
it  had  to  be  altered,  which  probably  meant  that  scar  tissue  was  reforming  (vide  notes  of 
case  128,  p.  60).  Patient  discharged  on  14.3.17. 


FIG.  3-. — Soon  after  wound. 


Fia.  33. — Result  of  plastic.     It  is  unfortunate  that 
the  healed  stage  of  this  case  was  not  recorded. 


48 


PLASTIC   SURGERY 


CASE  41 

This  is  an  example  of  a  large  soft-tissue  de- 
struction of  the  cheek  and  upper  lip  together 
with  a  small  loss  of  the  underlying  alveolar  bone 
of  the  maxilla.  The  tip  and  left  ala  of  the  nose 
arc  likewise  shot  away  ;  but  the  interest  of  the 
repair  is  confined  to  that  of  the  check.  The  first 
photograph  shows  the  suppurating  and  granula- 
tion stage  of  the  wound  10  days  after  the  injury. 

Two  months  later  the  plastic  operation  was 
performed,  by  which  time  the  wound  had  healed 
by  dense  scar  formation.  This  latter  was  freely 
excised,  and  the  picture  on  the  operating-table 
after  such  excision  very  closely  resembled  that  of 
the  original  wound.  The  repair  was  made  by 
transposing  a  large  flap  (A)  from  the  side  of  the 
chin  and  submaxillary  region  of  the  same  side,  i.e. 
an  ascending  flap.  Despite  a  mild  infection,  the 
repair  was  good.  The  secondary  gap  caused  by 
raising  flap  A  was  closed  with  some  difficulty, 
which  was  somewhat  eased  by  'a  secondary  in- 
cision (X)  represented  too  short  in  the  diagram. 

No  attempt  at  rhinoplasty  was  performed  at 
this  stage,  but  later  an  effort  with  small  local  flaps  was  made  to  modify  the  nasal  defect  with 
but  poor  result.  There  is  no  question,  in  view  of  the  later  development  of  rhinoplasty,  that 
an  excellent  repair  could  have  been  effected  on  the  lines  of  a  turncd-in  flap,  to  complete 
the  lining  of  the  tip  and  left  ala,  and  of  a  covering  from  the  left  frontal  region  carried  on 
a  tube-pedicle  flap,  as  in  case  627,  p.  244.  Patient  refused  further  treatment. 


FIG.  34.— Wounded,  1.7.16.    Condition,  1 1 . 7 . 1 G. 


Via.  35. — Result  4  weeks  after  operation,  per. 
formed  19.9.16.     No  attempt  at  rhinoplasty. 


FIG.  30. — Excision  and  flaps. 


REPAIR    OF    THE    CHEEK 


49 


CASE  144 

"  Loss  of  soft  tissue  without  serious  loss 
of  the  underlying  framework  "  is  the  category 
in  which  I  put  this  case.  The  patient  was 
wounded  on  October  llth,  1916,  and  was 
admitted  to  me  on  17.10.16.  The  wound 
is  a  very  remarkable  example  of  the  explosive 
type  and  it  is  instructive  to  note  how  this 
patient's  enormous  gaping  wound  healed 
without  more  than  ordinary  surgical  methods. 
I  think  this  case  teaches  a  lesson  to  the  in- 
experienced in  regard  to  the  way  the  camera 
occasionally  represents  an  inaccurate  concep- 
tion of  the  wound.  Thus,  fig.  38  repre- 
sents the  condition  when  the  tissues  were 
healed,  without  any  plastic  operation  what- 
ever. 

The  further  treatment  of  this  case  was 
undertaken  by  Captain  J.  L.  Aymard, 
R.A.M.C.,  and  consisted  of  excision  of  scars, 
with  satisfactory  results. 


FIG.  37. — Condition  on  admission. 


FIG.  .'{8. — The  result  of  healing  without  any 
operation. 


Fia.  39. — After  1st  excision  of  scar.     Note :  no  general 
facial  paralysis. 


50 


PLASTIC   SURGERY 


CASE   296 

This  case,  Private  W.,  wounded  on  1.7.16,  and  admitted  a  week  later,  is  an 
example  of  buccal  fistula  situated  in  the  exit  wound  of  a  bullet  which  entered  the 
left  check  and  carried  some  teeth  through  the  right  cheek.  In  fig.  40  is  shown  the 
exit  wound  with  buccal  mucous  membrane  everted  through  the  hole.  The  corner  of 
the  mouth  just  escaped  destruction.  This  is  one  of  the  cases  in  which  early  opera- 
tion is  indicated. 

An  operation  was  performed  on  21.7.16  under  general  anaesthesia.  The  buccal 
mucous  membrane  was  dissected  up,  invaginated,  and  retained  by  two  rows  of  purse- 
string  sutures.  Accurate  suture  of  the  rest  of  the  wound  was  not  attempted  at  this 
stage,  but  approximation  of  the  skin  was  produced  by  means  of  the  method  shown 
in  fig.  41.  Pieces  of  blanket  flannel,  to  which  are  sewn  dress-hooks,  are  fixed 
with  collodium  to  each  edge  of  the  wound  and  the  hooks  are  then  united  by  rubber 
bands.  Drainage  was  provided.  This  method,  as  advocated  by  Kazan  jian,  is  very 
valuable  in  the  early  approximation  of  wounds  when  deep  sutures  are  liable  to 
suppurate  and  to  produce  more  scar  tissue  than  was  previously  existing.  The  result 
of  this  operation  was  very  satisfactory ;  no  salivary  leak  occurred  and  the  wound 
healed  by  good  secondary  union.  There  was  a  long,  irregular,  depressed  scar  still 
present  at  the  end  of  two  months.  This  scar  was  then  excised,  but  there  was  a  slight 
breaking-down  near  the  angle  of  the  mouth.  The  scar  was  re-excised  some  six  weeks 
later.  The  result,  as  shown  in  fig.  42,  was  practically  perfect  and  the  man  was 
discharged  from  hospital  to  duty  on  June  13th,  1917. 


Fid.  40.— Buccal  fistula. 


FlO.  41. — Use  of  approximating  hooks 
and  clastic  (Kazanjian). 


FIG.  42. — Result  of  plastic  and 
excision  scar. 


REPAIR    OF    THE    CHEEK 


51 


CASE  101 

Lance-Corporal  W.,  wounded  on  7.10.16,  was  operated  on  by  me  on  15.1.17.  The 
wound  involved  part  of  the  malar  and  zygomatic  ridge.  It  will  be  noticed  also  that  botli 
eyelids  are  involved  in  and  dragged  outwards  by  the  scar.  Two  flaps  were  raised  on  each 
side  of  the  scar ;  from  the  lower  a  local  fat-flap  was  turned  upwards,  while  from  under 
the  upper  flap  a  small  portion  of  the  temporal  muscle,  with  its  overlying  fat,  was  turned 
downwards.  The  result  as  to  the  contour  was  good,  as  is  shown  in  fig.  44.  Under  local 
anaesthetic  four  months  later,  an  attempt  was  made  to  release  the  eyelids  from  the  outward 
drag.  This  was  only  partially  successful,  the  method  used  being  to  make  an  incision  \  in. 
external  to  the  outer  ocular  angle,  \  in.  in  length  across  the  line  of  the  scar  and  to  sew  up 
this  perpendicular  incision  horizontally.  To  further  raise  the  scar  a  small  tunnel  was  made 
from  this  incision  in  a  backward  direction  and  a  small  amount  of  paraffin  wax  imbedded. 
This  was  only  partially  retained. 

I  do  not  consider  that  either  of  the  last  procedures  is  to  be  recommended.  In  order 
to  release  the  outer  canthus  correctly  either  a  flap  should  have  been  laid  in  between  the 
end  of  the  scar  and  the  outer  ocular  angle,  or  else  a  sufficiently  large  skin-graft  applied  to 
produce  the  same  effect. 

In  regard  to  the  insertion  of  paraffin,  I  cannot  express  too  strongly  my  disapproval  of 
using  this  irritant  foreign  body.  Undoubtedly  the  best  method  of  using  paraffin  is  to  imbed 
a  definite  quantity  of  it  into  a  prepared  pocket.  The  immediate  results  are  often  very 
pleasing.  But  there  are  so  many  examples  known  to  all  surgeons  of  chronic  thickening 
of  the  parts,  induration  of  the  skin,  paraffin  tumours  and  other  complications,  that  its  use 
should  be  strongly  deprecated,  not  only  in  this  work,  but  also  in  all  forms  of  civilian  cosmetic 
surgery. 


Flo.  43. — -The  healed  stage.     Loss  of  bone  in  malar 
region.     Outer  canthus  dragged  out  by  scar. 


Fio.  44. — Result  after  an  attempt  partially  successful 
to  relieve  the  drag  on  the  outer  canthus. 


52  PLASTIC   SURGERY 


(c)    WITH   LOSS   OF   BONE 

The  severer  injuries  of  the  cheek  include  those  in  which  there  is  loss  of 
the  bony  frame-work.  One  particular  group  (1)  is  well  defined,  viz.,  that  in 
which  the  malar  prominence  is  wholly  or  sub-totally  lost.  I  have  chosen 
to  illustrate  this  group  by  four  cases  which  have  been  treated  by  means  of 
the  temporal  muscle  turned  forwards  subcutaneously.  In  one  of  the  cases 
(40)  a  previous  unsuccessful  implantation  of  a  celluloid  plate  was  made  and, 
in  the  following  case,  a  thin  celluloid  plate  was  inserted  over  the  temporal 
muscle  flap  with  satisfactory  results. 


CASE  28 

This  patient  was  received  in  a  healed  condition  on  18.5.16,  as  shown  in  fig.  45. 

He  was  wounded  26.9.15,  eight  months  previously,  no  record  being  available 
as  to  his  previous  condition.  On  30.6.16  I  operated  under  general  anaesthesia. 
After  excision  of  the  scar,  an  extension  of  incision  into  the  temporal  region  enabled 
me  to  detach  the  anterior  two-thirds  of  the  temporal  muscle.  This  muscular  flap 
was  separated  from  the  rest  of  the  muscle  and  swung  down  into  the  depression 
caused  by  the  loss  of  the  malar  prominence,  in  which  position  it  was  sutured 
with  catgut.  The  lower  part  of  the  wound  was  filled  up  by  means  of  local  fat -flaps. 
Horsehair  was  used  for  the  skin  edges.  In  fig.  47  the  result  of  this  operation  is 
shown.  The  dimple  underneath  the  left  eye  is  due  to  the  deep  suture  above  referred 
to,  which  retains  the  temporal  flap  in  position.  Primary  union  followed  this  operation. 
1  was  not  satisfied,  however,  with  the  reconstitution  of  the  left  orbital  margin ; 
hence,  a  piece  of  shaped  rib  cartilage  from  the  right  thorax  was  taken  and  inserted 
subcutaneously  to  form  the  outer  orbital  margin.  An  acute  infection  followed  this 
operation,  performed  on  21.7.16,  which  owed  its  origin  to  the  proximity  of  the 
orbital  cavity,  and  the  graft  was  removed  to  avoid  the  possibility  of  orbital  cellulitis. 
The  condition  rapidly  cleared  up  and  on  7.9.16  some  of  the  scar  tissue  was  excised 
under  local  anesthetic  (novocaine).  On  14.10.16  a  final  operation  was  performed  for 
the  still  further  improvement  of  the  contour  and  scar.  The  upper  part  of  the  vertical 
scar  was  excised,  skin  cut  on  the  slant,  and  a  bed  made  for  a  triangular  smooth 
piece  of  celluloid,  which  was  implanted.  The  skin  edges  were  carefully  sewn  up 
with  horsehair.  The  result  of  these  operative  procedures  is  shown  in  fig.  46. 

An  interesting  after-history  of  this  case  is  that,  on  26.3.17,  this  man  was  re- 
admitted suffering  from  a  localised  abscess  over  the  centre  of  the  celluloid  plate  and 
line  of  the  scar.  The  abscess  was  located  between  the  celluloid  and  the  skin  and 
had  not  burst.  The  celluloid  plate  was  freely  movable  and  the  abscess  was  not  painful. 
Within  a  week  suppuration  had  ceased  and  the  patient  was  again  discharged  with 
the  celluloid  plate  still  in  place.  It  is  interesting  to  note  that  this  is  one  of 
the  few  celluloid-plate  implantations  which,  in  my  experience,  have  been  retained. 
Another  point  of  interest  in  connection  with  this  case  is  the  suppuration  following  the 
cartilage  graft  operation.  In  view  of  later  experience  with  cartilage,  I  believe  that 
had  this  suppuration  been  drained,  there  is  the  possibility  that  a  large  amount  of  the 
cartilage  might  have  been  retained,  and  that  I  was  over  hasty  in  its  removal. 


REPAIR    OF    THE    CHEEK 


53 


FIG.  45. — Healed  condition. 


FIG.  46. — After  insertion  of  thin  celluloid  plate. 


Fid.  47. — Soon  after  temporal  muscle  implant. 


PLASTIC   SURGERY 


CASE  40 

Is  the  next  example  of  this  group.  The  healed  condition  of  this  case  will  be  seen 
in  fig.  48.  Private  F.  was  wounded  on  7.7.16.  The  wound  caused  loss  of  the 
right  eye  part  of  the  lower  lid  and  the  malar  prominence,  combined  with  the  external 
portion  of  the  orbital  ring.  At  that  time  I  was  giving  celluloid  plate  implantations  a 
thorough  trial  and  a  piece  of  celluloid  i  in.  thick  was  cut  in  the  shape  of  the  missing 
bony  substructure  and  implanted  in  situ.  The  result  was  a  failure,  as  ha?matoma  and 
suppuration  followed,  and  the  celluloid  had  to  be  removed.  On  30.1.17  it  was  possible 
to  perform  a  second  operation.  After  excision  of  the  scar,  the  temporal  muscle  flap 
was  swung  down  in  the  usual  manner  to  make  good  the  contour  but,  in  this  case, 
I  improved  the  operation  by  making  the  temporal  incision  in  the  hairy  scalp.  This 
"  inverted  U  "  shaped  incision  is  shown  diagrammatically  in  fig.  50  and  the  earlier  result 
of  this  particular  operation  is  shown  in  fig.  52,  while  the  later  result  of  the  implantation, 
witli  the  addition  of  an  artificial  eye,  is  to  be  seen  in  fig.  53. 


FIG.  48. — The  healed  condition  showing 
large  malar  loss  and  dragging  down  and 
out  of  the  outer  canthus. 


Celluloid.  Kiji 


FIG.  49. — The  first  operation  included  the  im- 
plantation of  a  shaped  piece  of  celluloid.  Failure. 
Removed. 


It  should  be  noted  that,  in  swinging  this  temporal  muscle  forwards  and  downwards, 
the  intervening  skin  had  to  be  undermined  and  raised  to  allow  the  muscle  to  be  passed 
underneath  it. 

Care  must  be  taken  to  detach  the  temporal  fascia  from  its  zygomatic  attachment. 
When  this  is  completed  the  muscle  flap  usually  comes  forward  as  far  as  is  necessary.  In 
some  cases  I  have  advanced  it  considerably  further  by  dissecting  downwards — towards  the 
coronoid  process,  at  the  back  of  the  muscle-flap.  When  this  is  done,  the  end  of  the  muscle- 
flap  can  be  easily  stitched  to  the  periosteum  at  the  side  of  the  nose,  vide  Case  215,  p.  71. 
Even  in  this  situation  the  temporal  muscle  continues  to  contract. 

Two  months  later  a  small  operation  was  performed  to  raise  the  lower  lid  at  the  inner 
and  outer  angles.  At  the  outer  angle  a  small  skin-flap  was  turned  into  the  socket  after  the 
adhesions  were  dissected  out,  while  at  the  inner  angle  a  small  wedge-shaped  piece  was 
removed  to  bring  the  angle  more  towards  the  middle  line.  This  enabled  an  artificial  eye 
to  be  carried,  but  was  not  entirely  satisfactory. 

The  result   was  perfect   as   far  as   the   contour   was  concerned,  and   the  temporal 


REPAIR    OF    THE    CHEEK 


55 


muscle,  in  its  new  situation,  had  a  certain  amount  of  contractile  power,  thereby  giving 
expression.     The  eye  socket  and  lower  lid  need  further  improvement. 

This   case  has  recently  been   seen,   eighteen   months   after  the  temporal  transplant 
operation,  and  the  contractile  power  of  the  muscle  is  undiminished. 


I  MS, 


FIG.  50. — Incision  and  preparation  for  the  author's 
operation  for  temporal  muscle  transplant. 


FIG.  51. — The  flap  of  muscle  sutured  into 
position. 


FIG.  52. — Soon  after  operation.     Showing  "  U  " 
temporal  incision.     Note  the  excellent  contour. 


FIG.  53. — Later.     Artificial  eye  fitted.     The 
lower  lid  still  requires  raising. 


56 


PLASTIC  SURGERY 


CASE   220 

Wounded  27.2.17.  First  operation,  27.6.17.— After  excision  of  scar,  a  flap  (fig.  55) 
was  swung  up,  and  split  to  enclose  the  corner  of  the  mouth,  the  larger  portion  going  to  the 
upper  lip,  the  consequent  gap  being  filled  by  advancement  of  flap  ('.  (figs.  56  and  57). 
Skin  and  mucosa  were  sewn  separately,  to  ensure  a  lining.  Mattress  sutures  were  employed 
down  as  far  as  the  upper  lip.  One  or  two  edge-to-edge  sutures  were  added  in  the  middle 
of  this  part,  the  result  being  best  here.  Elsewhere  interrupted  sutures  were  used,  giving 
a  better  scar  than  where  mattress  sutures  were  used  alone.  I  do  not  condemn  mattress 
sutures  because  of  this  experience,  as  I  find  that  a  scar  in  the  temporal  region  is  usually 
more  marked  than  one  in  the  mouth  region.  But  I  think  mattress  sutures  should  be  assisted 
by  the  addition  of  edge-to-edge  sutures.  The  upper  six  mattress  sutures  were  of  thread  ; 
hence,  possibly,  the  prominence  of  this  part  of  the  scar,  the  result  being  otherwise  good. 

An  observation  should  here  be  made  that  in  planning  the  flap  for  the  upper  lip,  I  allowed 
slightly  for  contraction.  None  has  occurred,  and  I  assert  that  where  no  raw  surface 
is  exposed,  none  will  occur  ;  and  the  teaching  that  the  flap  should  be  cut  one-third  or  more 
larger  than  the  gap  would  appear  erroneous.  When  an  epithelial  or  mucous  lining  can  be 
provided,  the  flap  should  be  the  exact  size  of  the  gap.  The  only  modification  I  make  on 
this  has  been  discussed  in  Chapter  I.  I  do  not  think  it  advisable  to  undertake  plastic 
operations  involving  mucous  cavities  without  seeing  that  the  complete  lining  is  available. 

A  second  operation  on  13.3.18,  consisting  mainly  of  excision  of  the  redundant  portion 
of  the  flap  above  described,  resulted  in  great  improvement  of  the  line  of  the  lip.  At  the 
same  time,  an  ovoid  piece  of  cartilage,  from  another  case,  was  inserted  into  the  eye  socket 
through  the  usual  conjunctival  incision.  The  result,  after  fitting  an  artificial  eye,  is  shown. 
The  lower  lid  needs  raising  a  trifle. 


t'ia.  04. — Recent  wound  of  cheek  and  upper  lip.  Fio.  55. — Diagram  of  excision  of  scar  and  of  flap,  A  B. 


REPAIR    OF    THE    CHEEK 


57 


FIG.  56. — Flap,  A  Bt  raised  and  split  to  form  corner 
of  mouth. 


FIG.  57. — Suture.     Flap,  O,  advanced  to  fill  gap. 
Note  relaxation  buttons. 


Fio.  58.— Day  after  operation,  showing  relaxation 
buttons  and  horsehair  mattress  sutures. 


FIG.  59. — Final  result.     Lack  of  muscle  power 
in  lower  lid  spoils  the  eye  effect. 


PLASTIC   SURGERY 


CASE   192 

Is  interesting  from  the  point  of  view  of  the  very  large  hollow  produced  by  the  loss 
of  the  malar  prominence,  infra-orbital  plate  and  adjacent  parts  of  the  superior  maxilla. 
Though  wounded  on  24.8.16,  this  patient  was  not  admitted  until  9.3.17,  when  the 
photograph,  fig.  60,  was  taken.  Temporal  muscle  operation  was  performed  on  16.4.17, 
but  the  operation  had  to  be  modified  by  the  addition  of  a  skin-flap.  It  should  be  noted 
that  there  was  a  small  sinus  leading  into  the  left  antrum  at  the  bottom  of  the  scar  and 
the  lower  lid  as  well  as  the  left  eye  had  been  shot  away.  The  flap  of  skin  was  turned 
down  from  the  left  temporal  region  from  the  line  of  the  temporal  artery.  It  is  marked 
"  A  A"  in  Professor  Tonks's  diagram,  fig.  61.  This  flap  was  slightly  bigger  than 
is  represented  and  was  swung  down  beneath  the  eye.  In  order  to  fill  the  gap  caused 
by  the  removal  of  this  flap,  a  swinging  flap  B  was  taken  from  the  scalp.  The  whole  result 
was  a  very  marked  improvement.  On  arriving  at  the  condition  shown  in  fig.  62,  one 
has  brought  into  the  bounds  of  possibility  the  question  of  the  reformation  of  the  left  eye 
socket.  A  certain  amount  of  movement  is  again  present  in  the  transplanted  muscle. 
The  secondary  closure  of  the  temporal  region  has  resulted  in  an  advancement  of  the  hairy 
scalp — a  condition  which  is  not  an  unpleasant  one. 

The  lymph-oedema  of  the  upper  lid  gradually  diminished.  The  treatment  of  the 
eye  socket  was  carried  out  for  me  by  Captain  C.  F.  Rumsey,  R.A.M.C.,  who  did  a  Tripier 
operation,  i.e.  swinging  a  stirrup  of  skin  from  the  upper  to  the  lower  lid,  the  flap  ends 
remaining  attached  for  the  blood  supply  to  both  ocular  angles.  The  resulting  condition 
was  such  that  the  socket  could  retain  a  glass  shell. 

At  this  stage  the  patient  was  discharged  from  the  Army,  to  return  later  for  the  com- 
pletion of  the  eye  socket. 


Fid.  60. — The  healed  stage  showing  large  malar, 
and  infra-orbital  bony  loss  of  lower  lid,  etc. 


FIG.  61.- — Shows  author's  temporal  muscle-flap  being 
brought  into  position,  and  a  temporal  skin- flap,  A  A,  to 
be  swung  down  beneath  eye  to  A'  A'. 


REPAIR    OF    THE    CHEEK 


59 


The  further  treatment  will  probably  consist  of  the  insertion  of  a  thin  strip  of  cartilage 
into  the  lower  lid  to  retain  it  at  a  correct  level.  It  may  be  necessary  to  deepen  the  socket 
by  means  of  an  epithelial  inlay. 


FIG.  62. — Result  of  this  operation. 


FIG.  63. — Result  of  Tripier  operation. 


FIG.  64. — Incision  for  Tripier  operation. 


FIG.  65. — Suture. 


60 


PLASTIC   SURGERY 


CASE  128 

Is  not  unlike  the  one  which  directly  precedes  this.  Rifleman  B.  was  wounded 
on  3.9.16  and  admitted  shortly  after  this  date.  No  photographic  record  of  the 
condition  at  this  stage  is  available  but  on  15.2.17,  the  day  of  operation,  the 
deformity  was  as  is  to  be  seen  in  fig.  66.  The  outer  third  of  the  left  upper  lip  was 
drawn  upwards  and  inwards  and  bound  down  against  the  ala  of  the  nose,  leaving  a 
triangular  opening  in  the  cheek  with  the  base  downward.  The  apex  of  the  triangle 
"|K'iis  into  the  antrum  while  a  large  scar  radiates  out  into  the  cheek  from  the  outer 
extremity  of  the  gap.  The  lower  lip  is  involved  in  this  cicatrix  and  is  drawn 


upwards. 

Operation    was    performed    on    15.2.17.       The    scar    tissue    was    excised    and    the 

lips  freed.  A  small  flap  of  skin  from  the 
upper  and  lower  margin  of  the  gap  was  turned 
to  complete  the  epithelial  lining  of  the  aper- 
ture, so  as  to  prevent  cicatricial  contraction 
later.  To  meet  this  inverted  epithelial  flap, 
a  mucous  flap  was  drawn  up  from  inside  the 
left  cheek.  The  mucous  membrane  at  the 
angle  of  the  mouth  was  completed  by  swinging 
round  a  portion  of  the  lower  lip  and  suturing  it 
with  deep  catgut  and  superficial  horsehair 
sutures  to  the  free  edge  of  the  upper  lip. 
Diagram  67  illustrates  the  method  of  freeing 
the  upper  lip.  The  corner  of  this  lip  was 
brought  down  to  help  to  form  the  corner 
of  the  mouth.  The  flap  was  then  outlined 
and  swung  up  to  complete  the  closure.  It  will 
be  observed  that  in  fig.  68,  a  vulcanite  support, 
taking  the  place  of  the  alveolar  margin  where 
it  was  wanting,  has  been  fitted  by  the  dental 
surgeon.  It  was  retained  in  position  until  the 
wound  was  well  healed,  which  occurred  with- 
out untoward  symptoms.  Black  silk  was  used 
on  this  occasion  to  unite  the  skin  edges. 
(25.1.17.)  Some  intra-buccal  adhesions  were 
cut  by  Captain  C.  F.  Rumsey  to  allow  a 
satisfactory  denture  to  be  fitted.  Photograph, 
fig.  69,  shows  the  condition  on  16.7.17. 

In  regard  to  the  cutting  of  intra-buccal 
adhesions,  I   feel  very  strongly  that  this  is  a 

method  which  docs  not  often  succeed ;  more  frequently  than  not  it  produces  more  scar 
tissue  than  before  the  treatment,  and  anything  in  the  nature  of  an  extensive  freeing  of  the 
lip  or  cheek  by  the  underlying  bone  by  undercutting  and  insertion  of  a  dental  appliance  is, 
in  my  experience,  doomed  to  failure.  I  admit,  however,  that  where  the  loss  of  mucous 
membrane  is  minimal  and  where  there  is  a  definite  band  of  scar  tissue  this  can  sometimes 
be  dealt  with  by  this  method.  In  all  other  cases  recourse  should  be  had  to  the  epithelial 
inlay  method  of  Esser. 


Fio.  66. — The  healed  condition,  15.2.17.  Note 
the  shield  on  the  obturator,  also  the  iodius  which 
spoils  the  photo. 


REPAIR    OF    THE    CHEEK 


61 


FIG.  G7. — Scar  excision  and  incisions.  The  inverted 
skin  and  mucous  membrane  flaps  cut  to  complete  the 
lining  are  not  shown  in  this  diagram. 


FIG.  OS. — Suture. 


Fia  01).— Result,  16.7.17. 


62 


PLASTIC   SURGERY 


CASE  14 

The  illustration,  fig.  70,  is  an  example  of  a  very  extensive  cheek  wound  with 
loss  of  the  supporting  bony  structures,  especially  of  the  superior  maxilla.  The  corner 
of  the  mouth  and  left  half  of  the  upper  iip  were  involved  in  the  destruction. 
Wounded  in  the  battle  of  the  Sommc,  the  first  plastic  operation  was  pcrfoimcd  thice 
months  later,  on  4.10.16,  on  which  date  the  condition  is  as  shown  in  fig.  71.  Dur- 
ing this  period  the  dental  surgeon  had  made  successful  efforts  to  reduce  the  fractures 
of  the  upper  and  lower  jaw  and  the  healing  process  apparently  diminished  the  loss 
of  tissue.  However,  on  excision  of  the  scar,  there  was  a  very  extensive  gap,  not 
considerably  less  than  that  shown  in  the  original  wound  photogiaph.  To  meet  this 
difficulty,  two  large  flaps  both  of  a  swinging  variety  were  taken.  The  larger  one,  A, 

comprised  the  remains  of  the  soft  tissues  of  the 
cheek  and  was  defined  by  means  of  an  incision  ex- 
tending from  the  side  of  the  nose  and  carried  outwards 
beneath  the  eye  to  the  malar  prominence;  while 
the  lower  flap,  B,  was  outlined  by  an  incision  carried 
down  from  near  the  corner  of  the  mouth  to  below 
the  mandible  in  the  sub-maxillary  region.  These 
two  thick  flaps  were  widely  under-cut  and  swung 
towards  each  other ;  the  upper  flap  completed  the 
gap  above  the  level  of  the  mouth,  while  the  lower 
one  was  sutured  along  its  lower  border.  Owing  to 
the  large  deficiency  of  mucous  membrane,  it  did 
not  seem  possible  to  complete  the  mouth  in  its 
original  size  and  some  sacrifice  in  length  of  the  lips 
was  perforce  made.  Relaxation  sutures  were  inserted 
to  retain  the  untouched  part  of  the  lower  lip  to  the 
large  cheek  flap.  Drainage  was  provided  at  a  suit- 
able spot.  The  result  of  this  plastic  operation  was 
very  satisfactory  in  so  far  as  one  operation  pro- 
duced a  result  which  satisfied  the  patient ;  but  it 
left  the  man  with  a  whimsical,  one-sided  expression 
which,  however,  was  not  entirely  unpleasant.  The 
rest  of  the  treatment  for  this  patient  consisted  in 
the  effort  to  get  union  of  the  right  horizontal 
ramus  of  the  mandible.  An  extensive  freshening 
of  the  ununited  fragments  was  carried  out  on  11.1. 17, 
but  no  union  resulted  after  a  period  of  three 

months.  On  25.4.17,  the  fracture  ends  were  again  exposed  but,  although  found  to  be  in 
good  apposition,  there  was  no  bony  union.  The  surfaces  were  again  freshened,  drilled 
and  wired  together  with  strong  iron  wire.  This  operation  was  carried  out  by  Captain 
J.  L.  Aymard,  R.A.M.C.,  and  Captain  F.  E.  Sprawson,  R.A.M.C.  No  union  had  occurred 
at  the  end  of  two  months  but,  at  the  end  of  five  months,  there  was  clinical  union 
of  the  fracture  and  the  patient  was  fitted  with  an  upper  and  lower  denture  which 
enabled  him  to  eat  a  semi-solid  diet.  He  was  discharged  from  the  Aimy  unfit  for  further 
service. 


FIG.  70. — Showing  condition  a  few  days 
after  wound  on  1.7.16.  Compare  this  with 
the  healed  stage,  which  gives  a  truer  con- 
ception of  the  loss  of  tissue. 


REPAIR    OF    THE    CHEEK 


63 


FIG.  71. — The  healed  condition,  4.10.16. 


Fio.  72. — Diagram  showing  excision 
of  scar  and  flaps  cut. 


Fio.  73. — Suture. 


Jfc 


Fio.  74. — Early  result  operation,  October  1910. 


Fio.  75.— September  1917. 


PLASTIC   SURGERY 


CASES    COMPLICATED    BY    SUPERIOR    MAXILLARY    LOSS 

A  less  defined  group  is  one  in  which  the  bony  support  of  the  upper  jaw 
is  missing.  The  loss  of  bone  may  be  in  the  alveolar  process,  the  anterior  wall  of 
the  antrum  or  in  the  infra-orbital  plate.  When  the  combined  bone  and  skin 
lesion  is  not  great,  the  difficulties  are  overcome  with  very  satisfactory  results ; 
but  when  there  is  a  great  loss  of  both  soft  and  hard  tissues,  as  in  Case  215, 
the  problem  is  one  requiring  much  thought. 


CASE   4 

This  man  was  wounded  in  the  upper  jaw  and  cheek,  including  the  corner  of  the 
left  upper  lip,  by  a  shell,  on  1.7.16.  The  bony  loss  consisted  of  the  alveolar  process 
and  the  lower  part  of  the  antral  wall.  The  condition  cleared  up  sufficiently  to  allow  the 


FIG.  70. — On  admission  three  weeks  after  wound. 

first  plastic  operation  to  be  peiformed  on  29.9.16.  The  irregular  scar  was  widely  excised. 
The  gap  produced  by  this  excision  is  well  shown  in  diagram,  fig.  78.  In  order  to  close 
this  gap  a  large  swinging  flap,  A'  B',  was  swung  upwards  to  meet  A  B,  and  the  mucous 
membrane  at  the  corner  of  the  mouth  was  rearranged.  On  2.11.16,  some  six  weeks 
later,  the  scar  tissue  was  excised  and  fat-flaps  brought  to  fill  up  the  hollow ;  this  was 
sutured  with  catgut,  the  skin  with  horsehair.  The  final  result,  seen  in  fig.  81,  is 
sufficiently  satisfactory.  When  fitted  with  dentures  on  discharge  from  hospital,  the 
patient  was  able  to  eat  most  articles  of  diet. 


REPAIR    OF    THE    CHEEK 


65 


FIG.  77. — The  healed  condition. 


FIG.  78. — Diagram  representing  excision  FiQ.  79. — Diagram 

of  scar  and  cutting  of  flap  A'  B'.  of  suture. 


a.  80. — Result  of  operation,  2(1. 9.1(i. 
Intermediate  stage. 


Fid.  81. — Result  of  operation,  2.11.16. 
Photo  taken,  2 1.11. 1C. 


66 


PLASTIC   SURGERY 


CASE   142 

The  early  condition  of  Private  R.  C.,  of  the  Scottish  Rifles,  wounded  on  1.9.16, 
is  represented  in  the  accompanying  figure  82.  The  condition  had  so  far  cleared 
up  that  I  was  enabled  to  perform  the  first  plastic  operation  five  weeks  after  this 
patient  was  wounded.  Unfortunately  the  photographic  record  of  his  healed  con- 
dition is  missing.  Too  much  was  not  attempted  and  the  result  was  sufficiently 
satisfactory.  Fig.  88  shows  the  result  of  this  operative  procedure,  of  which 
records  were  not  accurately  kept.  But  the  large  hole  in  the  left  cheek,  involving 
the  angle  of  the  mouth  and  a  portion  of  both  lips,  was  closed  by  two  swinging 
flaps,  one  from  above  and  one  from  below.  A  further  plastic  operation  was  per- 
formed by  me  three  months  later  and,  here  again  unfortunately,  the  details  are  not 
available.  The  condition  after  this,  when  healed,  is  as  shown  in  fig.  83.  At  this 
.stage,  Captain  Aymard  undertook  to  finish  the  condition.  After  excising  the  scar,  the 
lip  was  raised  and  sewn  by  the  method  shown  in  Professor  H.  Tonks's  diagrams,  the 
result  being  all  that  one  could  expect. 


Fio.    82.— Wounded  on  1.9.16.     Showing  condition 
a  few  days  later. 


FIG.   83. — Showing  result  of  two  plastic  operations 
(author),  10. 10. 1C  and  3.1.17. 


REPAIR    OF    THE    CHEEK 


67 


//?-<-^ 


FIG.  84.— Diagram  (Tonks)  of  operation  to  raise  corner  of  mouth. 


FIGS.  85  and  80. — To  show  result  of  operation,  13.3.17  (Aymard). 


(IS 


PLASTIC  SURGERY 


CASE  49 

Is  another  example  of  the  ravages  of  shell.  This  private  of  the  Royal  Minister 
Fusiliers,  whilst  still  in  the  condition  shown  in  the  photograph,  fig.  87,  was  found 
one  morning  looking  in  the  mirror  and  smiling  with  the  remaining  side  of  his  face. 
His  excuse  for  his  amusement,  he  explained  to  his  medical  officer,  was  that  he  was 
thinking  "  phwhat  an  aisy  toime  the  barber  would  have  in  future."  This  is  charac- 
teristic of  the  cheerful  resignation  of  face  cases  in  general.  The  extensive  injury  in 
this  patient  comprised  a  large  loss  of  substance  of  the  left  cheek,  corners  of  the 
mouth  and  upper  lip,  together  with  the  anterior  and  inner  walls  of  the  left  antrum 
and  alveolar  margin.  Strong  cicatricial  bands  formed  between  the  maxilla  and 
mandible,  the  body  of  which  was  likewise  fractured.  An  injudicious  attempt  to 
form  the  mucous  lining  of  this  cavity  was  made  on  26.10.16  without,  at  the  same 
time,  closing  in  the  gap  by  skin-flaps.  Although  the  operation  was  carried  out  with 
great  care  and  accuracy  the  want  of  skin  covering  over  the  mucous  membrane  flaps 
led  to  mal-nutrition  of  the  mucous  membrane  and  the  giving  way  of  the  stitches.  I 
have  tried  this  method  of  building  up  the  lining  at  a  separate  sitting  to  the  covering 
both  of  mouth  and  nose  openings,  but  have  not  had  satisfactory  results.  Both  lining 
and  the  covering  should  be  done  at  the  same  time  or,  if  it  is  impossible  to  find  a 
lining,  the  covering  should  be  epithelialised  first.  On  6.1.17  the  patient  still 
showed  a  very  deep  depression  on  the  left  side  of  the  face,  communicating  widely 
with  the  nasal  cavity.  Much  granulation  and  scar  tissue  was  present,  involving  the 
left  portion  of  the  upper  lip.  The  covering  to  this  gap,  after  extensive  excision  of 
scar,  was  formed  by  two  advancing  flaps  from  the  cheek,  as  indicated  in  the  dia- 
gram, fig.  88.  Similarly,  the  upper  lip  was  cut  across  below  the  nose  and  sutured 
to  the  freshened  surface  beyond  the  angle  of  the  mouth  and,  to  round  off  the  angle, 
a  small  mucous  flap  was  turned  upwards  from  the  lower  lip.  An  attempt  was  then 
made,  by  means  "of  a  free  muscle  graft  taken  from  the  vastus  externus,  to  close 

over  the  hole  into  the  nose  and  to  fill  up  the 
contour.  The  closure  was  then  completed,  a 
relaxation  suture  being  used  to  relieve  the  tension. 
The  whole  of  the  muscle  graft  became  infected 
and  apparently  sloughed  out.  This  is  borne 
out  in  other  similar  experiences  where  the  graft 
is  exposed  to  a  mucous  cavity.  Its  place,  how- 
ever, is  taken  by  granulation  tissue  and  later 
fibrous  tissue  which  very  materially  aided  in  the 
final  treatment  and  enabled  me,  three  months 
later,  to  implant  a  piece  of  cartilage  to  make 
good  the  loss  of  contour.  At  this  operation, 
date  11.4.17,  there  still  existed  a  small  per- 
foration into  the  nose  which  was  closed  by 
turning  in  over  it  small  scar  tissue  flaps.  A 
plate  of  cartilage  about  2  in.  by  1|  in  was 
taken  from  the  right  thoracic  wall.  The  result 
of  this  implantation  was  satisfactory  from  a 
cosmetic  point  of  view  but,  surgically  speak- 
ing, it  was  not  gratifying  on  account  of  a 
small  leak  into  the  nose,  causing  later  infec- 
tion of  the  graft.  The  infection  was  of  a 
mild  character,  however,  and  was  controlled  by 
Hicrs  cupping.  The  result  is  shown  in  photograph, 
FlG.  87. — Healed,  20.10.18.  fig.  90. 


REPAIR    OF    THE    CHEEK 


69 


\ 


Fia.   88. — Scar  excision  and  flaps.  FIG.  89. — Suture. 

Note :  another  incision  along  the  upper  lip  is  missing  in  the  diagram. 


FIG.  90. — After  plastic  and  cartilage  implant. 


70  PLASTIC   SURGERY 

CASE  105 

Is  a  typical  example  of  the  shattering  effect  of  an  exit  wound  of  a  high  velocity 
projectile  which  came  into  contact  with  a  dense  piece  of  bone.  A  considerable 
portion  of  the  right  angle  of  the  mandibles  as  well  as  the  tissues  overlying  it,  were 
blown  away,  producing  a  large  buccal  fistula.  After  many  months  of  suppuration 
and  operations  for  scqucstrotomy,  the  wound  eventually  healed.  Bits  of  the  mandible 
had  been  blown  down  into  the  neck  and  one  piece  was  removed  from  the  right  stcrno- 
mastoid.  Examination  of  notes  made  at  the  time  of  the  first  plastic  operation  reveals 
that  there  was  a  deep  scar  over  the  region  of  the  right  angle  of  the  mandible  and 
radiating  in  all  directions. 

On  16.1.17  this  operation  was  performed.  Under  general  anaesthesia  the  scar 
tissue  was  carefully  dissected  out.  Eatty  tissue  in  the  form  of  flaps  was  swung 
over  the  deepest  portion  of  the  wound  and  sutured  into  place.  The  skin  edges 
were  completely  united  with  continuous  silk  suture.  Examination  on  12.3.17  revealed 
that  the  result  of  the  previous  operation  was  excellent,  except  that,  from  a  contour 
point  of  view,  there  was  too  much  prominence  just  anterior  to  the  angle  of  the  jaw. 
On  examining  X-rays,  this  prominence  was  found  to  be  due  to  the  fact  that  the  body 
of  the  mandible  had  been  split  into  two  halves  by  the  projectile  and  that  the  union 
with  the  ramus  had  taken  place  by  attachment  to  the  inner  plate,  while  the  lower  border 
of  the  body  had  been  deflected  outwards  and  stood  out  as  would  an  exostosis.  It 
was  decided  to  remove  this  prominence  of  bone  and  to  cut  a  flap  of  thick  tissue  to 
be  swung  backwards  toward  the  angle  to  simulate  that  prominence.  The  result  of 
this  procedure,  on  12.3.17,  was  satisfactory  in  restoring  the  contour  of  the  jaw.  At 
this  time,  the  right  antrum,  which  was  still  somewhat  infected,  was  drained  through 
the  nasal  fossa.  There  still  remained  a  certain  amount  of  scar  tissue  which  was  excised, 
at  my  request,  some  five  weeks  later  by  Captain  Ayniard.  Owing  probably  to  tin- 
fact  that  this  operation  followed  too  soon  on  the  above,  no  further  improvement  was 
obtained,  as  there  was  some  slight  sloughing. 

I  think  the  most  astonishing  feature  of  this  case  is  the  fact  that  union  of  the  mandible 
was  obtained  after  such  a  long  period  of  suppuration  and  exfoliation  of  bone. 

The  wound  was  so  septic  that  the  idea  of  early  closure  was  unthinkable.  But  the 
question  arises  that  if  all  the  pieces  of  bone  that  were  later  exfoliated  had  been  taken  away 
in  the  early  stages,  in  order  to  clear  up  the  sepsis,  would  union  of  the  mandible  have  been 
obtained  ?  I  hardly  think  so.  In  my  experience,  as  a  rule,  this  class  of  explosive  wound, 
with  buccal  fistula,  rapidly  cleans  up  on  account  of  the  free  drainage.  But  in  this  ease- 
pieces  of  bone  had  been  driven  down,  not  only  into  the  sub-maxillary  region,  but  also  as  far 
back  as  the  sterno-mastoid  ;  the  drainage,  though  apparently  adequate,  was  not  really  so. 


Fio.  91.— Explosive  type  exit  wound.  FIG.    92.— After  moderately  successful  plastic  attempts  to 

improve  the  contour. 


REPAIR    OF    THE    CHEEK 


71 


CASE  215 

One  of  the  most  extraordinary  examples  of  loss  of  contour  that  I  have  had  under  my 
care.  Literally  the  whole  cheek  and  its  supports  have  been  blown  away ;  the  left 
lower  eye-lid,  swollen  with  lymphatic  obstruction  and  dragged  down  by  scar  tissvic, 
is  all  but  joined  to  the  angle  of  the  mouth,  which  is  likewise  distorted  by  the  cicatrix. 
Excepting  a  thin  plate  of  the  ascending  ramus  of  the  lower  jaw,  the  mandible  has 
been  destroyed  from  the  first  molar  region  to  the  joint.  The  left  eye  has  been  enucleated. 
Working  in  conjunction  with  Captains  C.  F.  Rumsey  and  Robertson,  under  whose  care 
this  case  was  placed,  it  was  decided  to  replace  the  remains  of  the  superior  maxilla 
and  mandible  as  far  as  possible  into  their  normal  positions.  An  impression  of  the 
upper  jaw  is  shown  in  fig.  93,  which  shows  the  extraordinary  approximation  of  the  two 
alveolar  borders. 

First  of  all,  the  scar  tissue  was  excised  at  the  left  corner  of  the  mouth  and 
carried  out  so  that  a  large  opening  was  made  into  the  buccal  cavity.  The  healthy 
mucous  membrane  was  drawn  out  and  stitched  round  to  the  margins,  so  that  there 
should  be  less  scar  formation.  In  regard  to  the  mandible,  there  was  a  plate  of  bone 
representing  the  left  ascending  ramus  lying  inwards  from  its  normal  position  and 
having  no  connection  with  the  joint.  Its  connection  to  the  scar  tissue  and  to 
the  anterior  fragment  of  the  mandible  was  cut  and,  thus  mobilised,  it  took  a  more 
normal  position.  As  far  as  the  maxilla  was  concerned,  a  small  chisel  was  entered 
between  the  left  canine  and  lateral  incisor  region  and  driven  backwards  along  the 
palate  without  injuring  the  mucous  membrane  on  the  oral  surface.  This  mobilised 
the  left  half  of  the  palate  so  that  it  could  be  easily  replaced  into  normal  position.  It 
was  held  there  by  a  temporary  support  while  a  proper  cap  splint  was  being  made. 
This  was  fitted  in  a  few  days  and  worn  for  some  months.  The  impression  of  the 
palate  as  it  is  now,  is  shown  in  the  accompanying  fig.-  94. 


FIG.  93. — Model  of  palate  before  its  forcible 
replacement. 


FIG.  94. — Same  after  the  left  half  of  the  palate  had 
been  levered  into  position  and  retained  there  by 
appliance. 


About  five  months  later  the  plastic  operation  proper  was  performed,  on    7.12.17. 

The  principle  of  this  operation  may  be  described  in  the  following  manner  :  The 
mucous  lining  was  provided  by  raising  the  available  mucous  membrane  from  below 
and  above  the  gap,  as  two  flaps,  and  then  suturing  together.  The  intermediate,  or 
supporting  structures,  were  provided  by  means  of  a  large  temporal  muscle  transplant, 


72 


PLASTIC   SURGERY 


Fids.  95  and  96. 
Destruction  of  the  greater  portion  of  the  left  side  of  the  face.     Note  the  contour. 


f 


Fio.  97. — Result  of  opening  up  wound  and  forcibly  FIG.  98.- — Diagram    of    flaps  for  next  stage.      The 

replacing  left  half  of  palate.     Retention  apparatus  in         mucous  membrane  lining  is  represented  by  the  shading. 
position.  C  is  a  post  auricular  flap. 


REPAIR    OF    THE    CHEEK 


73 


7  X 

FiO.  99. — Diagram'of  the  four  cartilage  implants. 


Fio.  100.— Final  result. 


FIO.  101. — Same.     Note  the  difference  in  contour 
as  compared  with  the  original. 


74  PLASTIC   SURGERY 

carried  out  in  the  usual  manner.  The  anterior  portion  of  the  left  temporal  muscle 
was  detached  from  its  origin  and  swung  down  beneath  the  eye  to  fill  up  the 
contour  of  the  check.  An  incision  in  the  hair  line  was  necessary  to  get  at  this 
muscle  and  it  was  then  possible  to  undermine  the  skin  from  the  zygomatic  region  to 
enable  this  muscle  to  be  detached.  Deep  catgut  sutures  holding  this  in  position  had 
for  their  purchase  the  left  lateral  aspect  of  the  nose.  The  main  skin-covering  was 
provided  by  a  large  transposed  flap  with  its  base  in  the  left  sub-maxillary  region 
and  its  apex  in  the  left  mastoid  region.  Its  design  is  well  shown  in  Professor  Hcmy 
Tonks's  diagrams.  It  met  the  main  deficiency  of  cheek  skin.  The  area  behind  tin- 
ear,  caused  by  the  removal  of  this  flap,  was  only  partially  closed  by  undermining  and 
advancement  of  the  skin  and  was  left  to  granulate.  The  flap  healed  remarkably 
well,  as  did  the  granulating  area,  and  this,  despite  a  chronic  suppurative  otitis  media 
which  was  present  in  the  left  ear  immediately  above  the  site  of  operation.  The 
healing  properties  of  this  particular  patient  are  indeed  remarkable. 

There  remains  to  describe  the  replacement  of  the  eye  socket.  This  was  merely 
sutured  into  a  higher  level  after  excision  of  the  scar  which  bound  it  down  to  the 
mouth  region.  The  corner  of  the  mouth  was  regulated  and  reconstituted  by  a  special 
cut,  which  enabled  the  upturned  corner  of  the  upper  lip  to  drop  to  its  normal  level. 

Examination  in  April  1918  revealed  the  fact  that  the  upper  jaw  was  firm  in  its 
new  position  and,  with  the  strip  of  bone  mentioned  above,  the  remains  of  the  left 
ascending  ramus  of  the  mandible  have  become  firmly  united  to  the  rest  of  this  bone, 
thus  producing  a  very  considerable  functional  improvement  as  far  as  mastication  is 
concerned.  The  jaw  cannot  be  opened  to  its  fullest  extent  but  the  trismus  is  not 
of  a  disabling  character. 

Having  a  large  piece  of  cartilage  to  spare  from  another  operation  case,  this  was 
inserted  subcutaneously  over  the  manubrium  sterni,  under  local  anaesthesia.  Five 
days  later,  under  general  anaesthesia,  the  cartilage  was  extracted  from  its  bed  and 
divided  into  four  pieces,  the  largest  piece  being  utilised  to  complete  the  contour  of 
the  mandible.  The  second,  a  long  thin  strip,  was  inserted  beneath  the  eye  socket 
to  retain  the  lower  lid  at  a  higher  level.  The  third  piece  was  placed  in  the  external 
orbital  region,  while  the  remaining  piece  was  inserted  into  the  temporal  region,  whence 
the  muscle  had  been  taken. 

I  am  greatly  indebted  to  Major  C.  W.  Waldron,  C.A.M.C.,  for  permission  to 
complete  this  Canadian  case  after  it  had  been  officially  transferred  to  him  for  treat- 
ment and  I  had  the  benefit  of  his  advice  and  assistance  at  this  latter  operation. 

It  is  still  doubtful  whether  a  really  satisfactory  artificial  eye  can  be  fitted  ;  but, 
as  this  man  states  he  is  returning  to  a  very  cold  part  of  Canada,  and  is  therefore 
not  anxious  to  have  this  fitted,  the  case  is  now  completed. 


"v, 


INJURIES   OF  THE    UPPER  LIP 


CHAPTER   III 
INJURIES  OF  THE   UPPER  LIP 

THE  repair  of  the  upper  lip  after  gunshot  wounds  is  to  be  considered  from 
three  main  points  of  view:  (1)  the  provision  of  the  skin-covering;  (2)  the 
provision  of  the  muscular  and  subcutaneous  layer ;  (3)  the  provision  of  the 
mucous  membrane  lining  and  vermilion  border. 

Taking  the  first  of  these  problems,  the  skin,  the  subjects  being  all  men, 
it  is  a  great  advantage  that  your  flap  should  contain  hair-bearing  follicles  : 
this  is  more  especially  the  case  since  it  is  quite  unusual  to  find  an  upper  lip 
that  is  totally  destroyed  and  does  not  present  portions  bearing  moustache. 
It  would  seem,  therefore,  that  the  flap  of  election  for  an  upper  lip  would  be 
an  ascending  flap  with  its  base  opposite  the  line  .of  the  upper  lip  and  its 
extremity  situated  in  the  lateral  chin  region.  This  method  violates  one 
important  principle,  viz.  the  direction  of  the  blood  supply,  as  it  is  obvious 
that  it  cuts  across  the  facial  artery  at  its  division  into  the  coronary  arteries. 
It  is,  however,  as  a  matter  of  practice,  a  satisfactory  flap,  but  there  have  been 
occasions  when  one  has  lost  portions  of  it  by  sloughing  caused  by  scar  tissue 
in  the  neighbourhood  of  the  blood  supply,  or  when  it  has  been  cut  too  long. 
Each  case  has  to  be  taken  as  a  problem  by  itself. 

The  second  main  method  of  making  new  portions  of  the  upper  lip  is  one 
which  includes  the  use  of  descending  lateral  nasal  flaps,  with  their  bases  in 
more  or  less  the  same  position  as  the  above-mentioned. 

This  flap  has  the  advantage  of  an  excellent  blood  supply,  and  shows  little 
tendency  to  depress  the  corner  of  the  mouth,  which  is  not  uncommon  with 
the  ascending  flap.  On  the  other  hand,  there  is  no  hair-bearing  skin  in  the 
flap,  and,  if  the  mucous  membrane  is  to  be  included,  there  is  only  a  small 
available  amount  under  the  flap,  and  its  length  is  limited  by  the  undesirability 
of  encroaching  on  the  lower  eyelid  region. 

Transference  of  hair-bearing  skin  from  a  distance  is  the  third  method  of 
external  covering  for  a  lip.  Hair-bearing  skin  is  swung  down  from  the  temporal 
region,  as  in  Case  324,  or  from  the  forehead,  or  from  the  temporal  region  on 
tube  pedicle  flaps  as  described  in  Principles. 

77 


78  PLASTIC   SURGERY 

These  arc  merely  methods  of  getting  hair-bearing  skin  from  the  scalp  to 
the  lip,  and  all  have  the  advantage  of  introducing  new  tissue  to  the  region  of  the 
mouth  and  of  leaving  no  secondary  facial  scars. 

A  rough  comparison  of  the  pros  and  cons  of  the  three  methods  follows, 
giving  ideas  which  may  be  found  useful  in  upper -lip  plastics. 

ASCENDING  : 

(a)  Advantages. — Hair-bearing,  ample  mucous  membrane  underlying, 

wide  mouth. 

(b)  Disadvantages. — Blood    supply    less    good,    more    twist,    depresses 

angle   of  mouth   if  any   of  lip   remains   at   corner,   muscular 
movement  indifferent.     Scars  noticeable. 

(c)  Indications : 

(1)  When  a  scar  runs  up  and  out  from  lip. 

(2)  When    there    is    accompanying    loss    of    cheek    near 

upper  lip. 

(3)  For  half-lips  when  there  is  a  good  half    moustache 

remaining. 


Fid.  102.— Ascending  flap.  FiO.  103.— Descending  flap. 

DESCENDING  : 

(a)  Advantages. — Good  blood  supply.     Angle  of  mouth  not  depressed. 

Muscular  movement  good.     Scars  negligible. 

(b)  Disadvantages. — No  hair.     Shortness  of  mucous  membrane  lining, 

apt  to  be  cut  too  short,  and  therefore  contracts  the  mouth 
and  puckers  the  lower  lip. 

(c)  Indications  : 

(1)  Where  a  portion  of  the  upper  lip  remains  near  the 

corner. 

(2)  When  a  scar  runs  down  and  out  from  the  mouth. 

MIXED  : 

(a)  Advantages.      } 

(b)  Disadvantages.^™*^*  th°SC  °f  "*  ab°Ve> 

(c)  Indications. — When  corner  and  small  part  of  adjacent   upper  lip 

remains   on   the   one  side  (diagram,  p.  85),  and  a  loss  right 


INJURIES    OF    THE    UPPER    LIP  79 

up  to  the  corner  and  extending  to  cheek  on  the  other  (see 
diagram).  This  method  slews  the  mouth  in  toto  to  one  side, 
but  has  given  me  one  good  result. 

See  Case  106,  p.  84. 
Scalp -flap. 

(a)  Advantages, — -Provides  moustache,  and  new  tissue  introduced  from  a 

distance,  no  secondary  scars  on  face.  The  lining  may  be  pro- 
vided at  same  time  by  including  portion  of  non-hairy  forehead. 

(b)  Disadvantages.- — Blood    supply    not    always   reliable    (I    have    seen 

several  failures  due  to  gangrene),  no  musculature  in  flap.  The 
operation  is  a  considerably  larger  affair. 

(c)  Indications. — (1)  Where  the  loss  is  great  and  much  scar  tissue  lies 

in  and  around  base  of  ordinary  flaps.  (2)  In  an  otherwise 
perfect  face  where  the  skin  covering  only  is  required.  (3) 
After  failure  of  other  methods. 


Fio.  104. — Temporal  artery  scalp  flap. 

In  sub-total  and  half-lip  losses,  the  same  principles  are  involved,  but  there 
are  a  few  additional  methods  which  deserve  mention. 

(a)  The  advancement  of  the  remaining  portion   of  the  lip  to  meet 

a  new  flap. 

(1)  Advantages. — Second  flap  need  not  be  cut  so  long. 

(2)  Disadvantages.— Very  apt  to  shorten  lower  lip  and  to 

make  it  pout,  also  to  upset  the  subsequent  applica- 
tion of  a  denture. 

(3)  Indications.— Small  losses,  and  to  make  full  use  of  exist- 

ing lip  and  red  margin.  No  harm  is  done  by  this 
incision,  and  it  is  a  useful  manoeuvre  provided  that 
the  corner  of  the  mouth  is  carefully  preserved. 


80  PLASTIC   SURGERY 

(b)  Advancement  with  parallel  cut  through  existing  corner — a  larger 

gain  of  length  is  obtained  than  by  the  simple  advancement. 
But  derangement  of  the  corner  occurs  and  always  requires 
a  secondary  correction,  often  an  enlargement  of  the  mouth. 

(c)  Advancing  swing — transferring  part  of  lower  lip  to  upper,  a  new 

corner  being  made.  This  method  has  its  uses,  but  my  ex- 
perience with  it  is  not  large  enough  to  see  clearly  its  limitations. 
When  the  cut  includes  the  mucous  membrane,  the  secondary 
deformity  is  very  considerable  and  difficult  to  correct ;  but 
when  the  skin  only  is  slid  over  the  deep  tissues  to  the  upper 
lip,  like  one  card  over  another,  the  secondary  deformity  is 
not  serious  either  functionally  or  aesthetically. 

A  further  method,  and  probably  the  best,  is  available  for  a  loss  of  the  central 
portion  of  the  upper  lip. 

(d)  An   ascending  whole  thickness   flap   is  let  in   above,   through   or 

below  the  existing  third  of  lip  on  one  side.  This  depresses 
the  angle  of  the  mouth  and  needs  a  subsequent  correction 
at  a  later  date  when  a  portion  of  this  flap  is  returned  to  the 
lower  lip  to  raise  the  angle.  This  secondary  correction  is  easy 
to  obtain.  Several  examples  are  illustrated  among  the  cases. 

(e)  The  ascending  bridge  flap  with  hair  for  moustache  is  indicated, 

when  skin  only  is  required.     The  pedicle  is  returned  to  the 
cheek.     Vide  Case  295,  p.   114. 
(/)   Similarly,   moustache   bridge   flaps   may  be   cut   from    the    scalp 

and  swung  down  to  the  upper  lip  with  successful  results, 
(g)  Method  of  Esser.      See  Annals  of  Surgery,  March  1917. 
Secondary  corrections  to  the  new  upper  lip  are  of  only  too  frequent  neces- 
sity.    I   have   seldom   produced   a   satisfactory   upper    lip   in   one   operation. 
Corrections  of  the  level  of  the  mouth  corners,  of  the  red  margin,  of  microstoma, 
of  adhesions  between  lip  and  jaw,  and  of  general  tightness,  all  present  problems 
which  cannot  be  usefully  discussed  at  the  present  time. 

In  regard  to  the  second  provision  for  an  upper  lip,  the  muscles  and  sub- 
cutaneous tissue,  both  the  main  methods  of  repair  above  mentioned  provide  this 
tissue  body  for  the  new  lip.  Thus,  the  ascending  flap  from  the  chin  region 
includes  the  orbicularis  and  various  portions  of  muscles  attached  in  the  region 
of  the  chin,  while  the  descending  flap  has  muscular  fibres. 

It  is  doubtful  whether  either  of  these  muscular  flaps  gives  as  much  move- 
ment in  its  new  position  as  the  main  flap  for  making  a  lower  lip,  which  is 
mentioned  in  the  next  section.  But  in  both  cases  a  certain  amount  of  muscular 
function  appears  to  persist,  It  is,  however,  to  be  admitted  that  the  move- 


INJURIES    OF    THE    UPPER    LIP  81 

ments  of  a  new  lip  are  very  inferior  to  that  of  the  normal,  and  as  the  form  of 
the  lip  depends,  to  a  very  great  extent,  on  the  normal  muscular  poise,  it  is 
obvious  that  the  reformation  of  a  normal  upper  lip  is  not,  so  far,  within  the 
maximum  of  possibility.  The  most  that  I  foresee  as  a  result  is  a  new  upper 
lip,  which,  in  a  position  of  rest,  gives  a  normal  appearance.  The  production 
of  the  filtrum  is  a  subtlety  which  does  not  seem  to  be  worth  attempting 
until  one  has  produced  a  higher  grade  lip  than  at  present.  I  have  made 
attempts,  as  in  Case  177,  in  which  the  tissue  of  the  new  lip  was  very  thick 
under  the  nose,  and  gradually  became  thinner  as  the  red  border  of  the  lip 
was  approached,  to  roll  down  the  flap  of  subcutaneous  tissue  from  the  upper 
and  nasal  aspect  of  the  lip  to  the  free  border.  This  partially  succeeded.  It 
may  be  that  very  thin  strips  of  cartilage  inserted  under  the  skin  might  produce 
a  satisfactory  edge  to  a  lip  as  well  as  a  filtrum. 

In  regard  to  the  provision  of  the  mucous  membrane,  this  is  a  matter 
which  requires  very  close  examination  in  each  case,  for  frequently  a  good  deal 
of  useful  mucous  membrane  has  been  saved  after  the  injury.  Frequently 
small  flaps  of  skin  in  the  neighbourhood  can  be  turned,  with  .  their  skin 
surfaces  inwards,  to  keep  the  lip  free,  and,  in  addition,  the  ascending  flap 
mentioned  above,  which  not  only  contains  skin  and  muscle  as  well,  can  be 
made  to  include  mucous  membrane.  In  such  a  case  the  whole  new  upper 
lip  is  made  with  one  design.  Personally,  I  have  not  used  this  flap  on  many 
occasions,  either  because  it  was  not  necessary,  or  because  some  complicating 
scars  were  present.  The  only  disadvantage  of  taking  the  mucous  membrane 
with  this  ascending  flap  is  a  certain  amount  of  shortening  of  the  cheek 
mucous  membrane,  and  if  there  is  any  septic  process  occurring  after  the 
operation,  one  is  liable  to  create  adhesions  in  one  or  other  sulcus  affecting 
the  efficiency  of  mastication;  but,  with  a  well-cut  flap  and  proper  attention,  I 
do  not  think  this  complication  should  occur. 

Another  method  of  providing  mucous  membrane  for  a  vermilion  border 
of  the  new  upper  lip  is  one  involving  the  transference,  in  two  stages,  of  the 
mucous  membrane  flap  from  the  lower  lip. 

If  the  vermilion  border  missing  is  situate  on  the  outer  third  of  the  lip,  then 
the  mucous  membrane  flap  from  the  lower  will  have  its  base  near  the  corner  of 
the  mouth.  But  if  the  missing  portion  of  the  vermilion  border  is  in  the  central 
portion  of  the  upper  lip,  a  flap  is  conveniently  turned  up,  in  a  vertical  direction, 
from  the  centre  of  the  lower  lip,  with  its  base  towards  the  free  margin  of  the 
lip. 

In  this  latter  event,  it  is  necessary  to  stitch  the  two  lips  together  while 
union  is  taking  place  and  before  the  pedicle  is  divided.  For  the  details  of  such 
operation  see  Case  184,  p.  150, 

0 


82  PLASTIC   SURGERY 

A  few  other  general  points  about  upper  lips  are  worthy  of  mention.  Com- 
plete loss  of  the  upper  lip  does  not  occur,  in  my  experience,  without  the  loss 
of  the  pre-maxilla,  and  quite  half  the  difficulty  of  forming  a  satisfactory  upper 
lip  in  a  complete  loss  is  to  be  found  in  the  difficulty  of  restoring  the  bony  contour 
by  means  of  a  dental  appliance.  There  are  usually  very  few  teeth  left  in  the 
upper  jaw  on  which  to  carry  a  satisfactory  prosthesis ;  in  addition,  one  fre- 
quently makes  a  mistake  in  making  an  upper  lip  with  flaps  insufficiently  long, 
and  consequently  there  is  a  tightening  and  flatness,  and  the  denture  becomes 
very  liable  to  be  pressed  on  and  easily  displaced.  Another  of  the  mistakes 
that  I  have  perforce  fallen  into  is  that  one  did  not  at  first  realise  that  the 
prominence  of  the  central  portion  of  the  upper  lip  was  due  not  entirely  to  the 
pre-maxilla,  but  to  what  I  describe  as  the  suspension  of  the  upper  lip  from 
the  columella  of  the  nose.  The  upper  lip  hangs  like  a  curtain  from  the 
columella.  With  one's  fingers  in  the  vestibules  of  the  nose,  gripping  the 
columella,  one  finds  that  the  upper  lip  is  suspended  by  that  portion  of  the  nose. 
Looking  at  a  normal  upper  lip  from  the  side,  one  is  aware  that  it  runs  well  up 
into  the  columella,  whereas  in  actual  practice  the  majority  of  the  new  upper 
lips  do  not  present  this  suspension  from  and  incorporation  into  the  nose ; 
they  seem  to  run  straight  across  from  one  ala  to  the  other  in  an  abnormal 
manner.  Frequently,  of  course,  this  condition  results  from  the  accom- 
panying loss  of  the  columella  and  anterior  nasal  spine ;  but,  in  repairing 
the  upper  lip,  the  anatomical  attachments  that  I  have  mentioned  should  be 
aimed  at. 

I  am  indebted  to  Professor  Henry  Tonks  for  pointing  out  to  me  the  defects 
in  the  upper  lip  from  this  point  of  view,  especially  from  the  loss  of  the  pre- 
maxillary  prominence,  and,  on  thinking  the  matter  over,  the  suspension  of 
the  upper  lip  from  the  columella  presented  itself  to  me. 

It  is  quite  reasonable,  as  mentioned  above,  to  turn  a  portion  of  the  lower 
lip  into  the  upper;  but  when  this  process  is  overdone,  the  result  is  most 
unpleasant.  The  greatest  care  must  be  exercised  in  this  manoeuvre  to  see 
that  ugly  deformity  of  the  angle  of  the  mouth  is  not  produced. 

In  comparing  it  with  the  lower  lip  repair,  it  would  seem  to  me  that 
the  shortening  of  the  upper  lip  is  a  very  much  greater  defect  than  a  similar 
shortening  of  the  lower.  In  a  few  words,  it  is  quite  possible  to  sew  up  a  lower 
lip  which  has  lost  nearly  a  third  of  its  bulk  without  causing  either  a  serious 
functional  or  aesthetic  deformity,  whereas  a  similar  loss  of  the  upper  lip  cannot 
be  produced  without  very  serious  impairment  of  function,  accompanied  by 
a  most  unpleasant  effect,  and  it  is  probably  for  this  reason  that,  in  my 
experience,  the  formation  of  the  upper  lip  is  more  difficult  than  that  of  the 
lower. 


INJURIES    OF    THE    UPPER    LIP  83 


ILLUSTRATIVE    CASES 

Those  that  I  have  chosen  to  demonstrate  loss  of  the  upper  lip  and  its  repair 
have  been  grouped  in  the  order  of  decreasing  severity ;  thus  the  first  few  are 
examples  of  complete  loss,  whereas  the  last  are  of  minor  injury  of  the  lip. 

Total  loss  of  the  upper  lip,  as  I  have  already  stated,  is  not  met  with  without 
the  accompanying  loss  of  the  pre-maxilla,  either  in  part  or  as  a  whole.  Fre- 
quently these  severe  injuries  of  the  upper  lip  involve  the  lower  portion  of  the 
nose,  and  in  some  cases  the  whole  of  the  nose,  as  well  as  the  pre-maxillary 
and  central  two-thirds  of  the  upper  lip,  has  been  destroyed  by  one  projectile. 

The  problem  of  the  repair  is  to  a  large  extent  dependent  on  this  loss 
of  the  pre-maxilla.  I  have  divided  the  severe  upper  lip  injuries  into  those 
accompanied  and  those  unaccompanied  by  loss  of  the  bony  structure.  It 
is  with  the  bony  loss  type  of  lip  that  the  aid  of  the  dental  surgeon  must  be 
urgently  invoked.  In  all  cases  a  prosthesis  should  be  prepared,  which  will 
ensure  that  the  new  lip  is  efficiently  supported  from  underneath,  and  at  the 
same  time  that  the  incisions  of  the  mucous  membrane  do  not  lead  to  cicatricial 
contraction  of  the  upper  sulcus.  It  should  be  designed  so  as  to  have  as  perfect 
a  fit  as  possible,  and,  if  necessary,  it  may  be  supported  from  the  lower  teeth 
or  even  from  a  lower  denture.  This  dental  appliance  must  be  so  made  as 
to  ensure  that  the  new  lip  is  of  sufficient  size.  After  the  under-lining  of  the 
new  lip  is  satisfactorily  made  of  mucous  membrane  or  skin  turned  inwards, 
very  little — if  any — contraction  need  be  allowed  for,  but  if  any  raw  areas  on 
the  under-surfaces  of  the  lip  are  exposed  to  the  buccal  secretions,  ulceration 
will  cause  severe  contraction.  No  upper  lip  should,  therefore,  be  designed 
which  does  not  include  its  most  important  element,  the  mucous  lining.  In  this 
class  of  case,  the  following  is  a  good  example  : 


84  PLASTIC   SURGERY 

CASE   106 

This  R.A.M.C.  Orderly  was  wounded  by  a  shell  fragment  on  28.4.16,  and 
admitted  for  plastic  treatment  on  27.6.16,  two  months  after  he  actually  received 
his  injury.  His  condition  was  most  repulsive — complete  loss  of  the  upper  lip  was 
accompanied  by  total  loss  of  the  pre-maxilla  and  by  destruction  of  the  anterior 
portion  of  the  floor  of  the  nose,  and  of  the  adjacent  walls  of  left  antrum.  The  nose 
was  considerably  deformed  and  dragged  downwards  in  the  healing  process.  A 
satisfactory  dental  appliance  having  been  made  by  Captain  L.  A.  B.  King,  L.D.S., 
and  his  staff,  the  patient  was  operated  upon  under  general  anaesthesia. 

Preliminary  laryngotomy  was  performed  by  the  Butlin  method  and  the  anaesthetic 
given  through  this  opening.  The  pharynx  was  packed  off  so  that  blood  did  not 
enter  the  lower  air  passage.  The  main  design  of  the  operation  is  shown  in  diagram  107, 
which  needs  little  amplification.  The  main  part  of  the  upper  lip  was  made  by  a 
descending  lateral  nasal  flap  which  was  swung  from  the  right  side  across  to  the  left. 
This  flap  included  muscle  and  mucous  membrane,  and,  in  order  to  lengthen  it,  the 
knife  was  carried  through  the  corner  of  the  mouth  in  a  parallel  direction  to  the  first 
cut.  This  flap  reached  about  two-thirds  of  the  way  across  the  lip.  On  the  left  side, 
the  broad  flap,  as  shown  in  the  diagram,  was  outlined  and  swung  up  to  meet  its 
fellow.  This  flap  was  broader  at  its  base  than  at  its  extremity ;  it  also  included 
mucous  membrane.  In  regard  to  the  nose,  the  left  ala,  which  was  tied  down  to  the 
remains  of  the  nasal  floor,  was  elevated,  and  re-sutured  into  position.  On  the  whole 
the  result  of  this  operation  was  fairly  satisfactory;  the  mouth,  however,  was  small 
and  the  upper  lip  did  not  present  very  good  lines,  nor  did  the  muco-cutaneous 
junctions  show  at  all  as  a  vermilion  border.  The  manoeuvre  of  pulling  over  the  right 
flap  towards  the  left  had  narrowed  the  mouth.  Subsequent  correcting  operations 
were  performed  on  various  dates.  Under  a  local  anaesthesia,  the  right  corner  of  the 
mouth  was  enlarged  by  a  simple  incision  and  the  pulling  out  of  the  mucous  mem- 
brane. On  16.1.17  examination  notes  read  that  deep  scars  were  radiating  from  the 
left  angle  of  the  mouth  into  the  lower  lip,  while  other  scars  were  present  at  the 
junction  of  the  flaps  making  the  new  upper  lip,  and  in  the  left  cheek.  All  these  scars 
were  more  pronounced  than  usual.  Under  general  anaesthesia,  they  were  dissected  out 
—that  in  the  upper  lip  was  dissected  out  in  a  diamond-shaped  fashion,  there  being 
a  slight  notch  at  this  point,  and  sewn  up  vertically  to  give  extra  depth.  This 
manoeuvre  was  quite  satisfactory,  but  not  quite  sufficiently  radical.  The  notch  in  the 
lower  lip  was  rearranged  by  swinging  flaps,  as  shown  in  fig.  110.  A  small  excision 
was  carried  out  just  above  the  right  angle  of  the  mouth  to  raise  the  same,  while  the 
ala  of  the  left  nostril  was  carried  farther  to  the  left.  All  sutures  were  carefully  made 
with  interrupted  horsehair.  The  results  of  these  corrections  were  satisfactory  on  the 
whole,  except  that  the  scar  lines  were  still  very  prominent.  Three  months  later, 
17.4.17,  the  mucous  membrane  of  the  upper  lip  was  brought  farther  out  to  become 
more  prominent,  and  one  of  the  scars  of  the  lower  lip  was  re-excised  and  sewn  up 
with  subcutaneous  catgut.  The  scar-line  thus  produced  was  again  unsatisfactory,  and 
it  was  apparent  that  this  man's  skin,  though  it  always  united  well  by  primary  union, 
was  of  an  unusual  character.  The  reason  may  be  forthcoming  in  the  fact  that  there 
is  a  considerable  amount  of  acne  present.  The  later  history  of  these  scars  is  inter- 
esting, as  they  are  apparently  becoming  more  obliterated  than  usual  by  tiny  bridges 
of  skin  growing  across,  and  already  one  of  the  scars  is  invisible. 

This  case  has  opened  up  the  question  of    the  histology  of    good  scar  production. 

The  two  small  palatal  perforations  were  closed  by  mucous  membrane  flaps  on 
7.6.17;  one  of  the  flaps  partially  broke  down.  In  order  to  fill  up  the  depression 
in  the  left  cheek,  the  lateral  scar,  shown  in  fig.  1C  9,  was  excised,  and  the  skin  under- 
cut in  its  neighbourhood  and  free  fat-graft  from  the  subcutaneous  tissue  of  the 
abdominal  wall  inserted;  the  skin  was  sewn  up  with  subcutaneous  horsehair. 

Like   many  other  fat-graft  operations  in  this  region,  the  union  was  primary  and  it 


INJURIES    OF    THE    UPPER    LIP 


85 


was  not  until  a  week  after  the  stitches  were  out  that  a  slight  oozing  of  fat  occurred 
followed  by  some  suppuration.  This  condition  was  cleared  up  with  Biers'  cupping,  and 
th.3  final  result  is  satisfactory.  Even  after  the  first  operation,  it  was  a  great  satisfaction 
to  hear  this  man  speak  with  his  native  brogue  again.  Before  operation  he  was  a  man 
who  was  so  sensitive  about  his  appearance  that  he  did  not  like  mixing  with  his  fellow 
patients  or  with  the  outside  public. 


Fio.  105. — On  admission. 


FIG.  100. — Prosthesis  in  position.     (Discoloration 
due  to  Iodine.) 


Fio.  107. — The  (laps.     Right,  descending.     Left,  ascending. 


Fio.  108. — Suture. 


80 


PLASTIC   SURGERY 


Fid.  109. — First  result. 


Fio.  110. — Upper  and  lower  lip  corrections. 
Incisions. 


Fio.  111.— Suture. 


FIG.  112. — Final. 


INJURIES    OF    THE    UPPER    LIP 


87 


CASE  525 

An  example  of  total  loss  of  upper  lip.  This  man  on  admission  to  a  Base  hospital  in 
France  still  possessed  an  upper  lip,  but  it  was  in  a  damaged  and  semi-gangrenous  condition, 
and,  in  spite  of  the  utmost  care,  the  whole  thing  sloughed,  leaving  the  condition  shown  in 
fig.  113.  Partial  attempt  to  relieve  the  deformity  had  been  made  prior  to  admission  to  my 
service,  the  result  of  which  procedure  is  shown  in  fig.  114.  The  mouth  is  very  contracted 
and  the  lower  lip  pouted.  The  new  upper  lip  is  insufficient  and  short,  while  the  whole  nose 
is  lengthened  and  depressed.  It  was  decided  to  reconstruct  the  wound  and  to  replace 
the  nose  in  its  normal  position. 

Operation,  23.7.18.  Scar  tissue  in  the  centre  of  the  new  upper  lip  was  excised,  as  was 
that  around  the  attachment  of  the  nose.  The  stumps  of  the  upper  lip  were  allowed  to 
retract  into  their  normal  position,  in  which  situation  the  mucous  membrane  was  brought 
out  and  sewn  to  the  skin.  No  attempt  was  made  to  repair  the  lip  at  this  stage.  The  nose 
was  gradually  freed  until  it  could  be  raised  into  its  position.  The  only  blood  supply  re- 
maining to  the  nose  being  a  small  bridge  in  its  upper  part,  this  undercutting  and  raising  had 
to  be  done  with  the  greatest  of  patience  and  care.  The  alae  were  brought  together  beneath 
the  tip  and  the  nose  sutured.  This  was  a  very  risky  procedure,  and  I  was  more  than  thankful 
for  its  satisfactory  result. 

It  now  remained  to  repair  the  upper  lip  uncomplicated  by  the  false  attachment  of  the 
nose.  Elaborate  diagrams  by  Mr.  Hornswick  of  this  operation  are  included,  and  show  the 
developments  of  diagrammatic  illustration  for  this  form  of  record  in  an  exceedingly  difficult 
case. 

Haps  A  and  B  from  the  left  and  right  cheeks  respectively  were  turned  skin-surface 
inwards  over  a  large  dental  appliance  fitted  by  Captain  W.  Kelsey  Fry,  M.C.,  R.A.M.C.  ; 
they  were  sutured  together.  The  mucous  membrane  off  the  stumps  of  the  upper  lip  was 
cut  into  two  flaps  (C  and  D),  one  on  each  side,  and  by  advancement  came  to  lie  along  the 
lower  borders  of  A  and  B,  where  they  were  sutured,  not  only  to  each  other,  but  also  to  A 
and  B.  These  mucous  membrane  flaps  were  broad  enough  to  complete  the  lower  border 
and  to  curl  round  for  the  vermilion  edge  of  the  new  lip. 


FIG.  113. 


Fid.   114. 


FIG.  115. 


FIG.  113. — Total  loss  of  upper  lip  and  underlying  bone.     (Photo  taken  in  France.) 

FIGS.  1 14,  1 15. — Condition  on  admission.  These  show  the  indifferent  result  of  making  a  lip  by  advancement 
methods.  Both  the  lips  and  the  nose  are  backwardly  displaced.  The  mouth  is  contracted,  and  the  lower  lip  is 
pouted.  [Note  :  These  defects  have,  in  this  case,  been  accentuated  by  the  failure  of  part  of  the  flaps  to  survive.] 


88 


PLASTIC   SURGERY 


The  skin  covering  was  the  next  problem,  and 
double  ascending  flaps  A'  B'  were  taken  from  the 
lateral  aspects  of  the  chin  and  sutured  together  over 
the  inturned  flaps  A  and  B.  To  their  lower  borders 
were  sutured  the  lower  free  borders  of  the  mucous 
membrane  flaps  C  and  D. 

The  secondary  closure  did  not  present  any  great 
difficulties.  The  most  anxious  part  of  the  operation 
was  flap  A',  which  had  a  great  deal  of  scar  tissue  in 
it.  In  fact,  the  only  clear  bit  of  skin  was  a  minute 
portion  on  its  lower  border.  I  had  great  fears  of 
losing  the  whole  flap.  However,  the  blood  supply 
returned  and  was  maintained  satisfactorily.  Apart 
from  some  slight  breaking  down  of  the  suture  line 
A'  B',  the  healing  process  was  satisfactory.  The 
columella  had  been  brought  out,  lengthened  and 
sutured  in  the  middle  of  the  upper  lip  :  this  wants 
rearrangement,  as  is  evidenced  from  the  photograph 
which  merely  represents  the  present  stage  of  the 
repair. 


Fio.  116. — Diagram  of  the  ex- 
cision of  scar  tissue,  practised 
to  bring  about  replacement  of 
the  nose  upwards  and  forwards, 
and  to  allow  the  corners  of  the 
mouth  to  separate. 


Fio.  117.  Fio.  118. 

l'io.  117. — Shows  the  result  of  putting  into  practice  the  author's  principle  of  replacing  the  remnants  into 
normal  position.  Skin  is  sewn  to  mucous  membrane  so  that  no  raw  area  occurs.  An  upper  prosthesis  is  now 
fitted,  replacing  the  lost  hard  tissues. 

Fio.  118.— Profile  of  same  stage,  showing  the  vast  improvement  in  the  nose.  No  apparatus  was  employed 
to  retain  the  nose. 


FIG.   1 1 9.— The  incisions. 


Fio.   120.— The  flaps. 


Fio.   121. — Suture  of  the  interned 
and  mucous  flaps. 


Fio.   122. — Final  suture.  Fio.   123. — Sectional  view. 

FIGS.    119—123. — A   and   B  =  cheek   flaps,   inverted   to   form   the  posterior  epithelial  surface  of  the  new  lip. 

C  and  D  =  mucous  membrane,  advanced  flaps  taken  from  the  lip  stumps  to  form  the  mucous  membrane 
lower  border  of  the  new  lip. 

A'  and  B'  =  ascending  cheek-chin  flaps  to  form  the  outside  skin  covering  to  the  whole.  The  raw  areas  caused 
by  the  cutting  of  these  two  flaps  is  closed  by  approximation. 


FIG.  124. 


Fid.  125. 


Fio.  124.— Result  of  the  six-flap  plastic  operation  portrayed  in  the  diagrams.     A  permanent  upper  prosthesis 
;  fitted. 

FIG.  125. — Profile  of  result.     Note  the  pi 
apparatus  representing  the  missing  maxilla. 


S  FIG°  125.— Profile  of  result.     Note  the  prominence   of   the  new  upper  lip,  which   is  supported  by  a  vulcanite 


90 


PLASTIC   SURGERY 


CASE   7 


In  the  next  case  also — one  of  similar  but  less  destruction  of  upper  lip — the  prc-maxilla 
was  destroyed ;  but  a  small  and  valuable  piece  of  upper  lip  remained  at  the  left  angle  (a 
point  not  evident  in  fig.  126,  taken  a  fortnight  after  the  wound).  Fig.  127  shows  the  healed 
condition,  a  remarkable  improvement.  The  lower  lip  has  become  almost  normal,  and 
little  scarring  has  resulted,  but  the  remains  of  the  left  upper  lip  have  become  attached 
and  drawn  upwards. 

Primary  suture  was  expressly  avoided,  and  the  main  repair  of  the  upper  lip^was  per- 
formed over  an  effective  dental  support  ten  weeks  after  the  wound.  Lateral  nasal  flaps 
were  used  on  both  sides  (fig.  128),  and  by  advancement  of  the  mucosa  of  the  left  side,  it 
was  made  to  cover  half  the  under  aspect  of  the  new  lip,  and  to  line  not  only  the  left  but 


FIG.  120. — On  admission  twelve  days  after  injury. 


Fio.  127. — The  healed  condition. 


part  of  the  right  side.  Ihe  lining  was  completed  by  advancing  a  descending  flap  of  mucous 
membrane  from  the  right  cheek  near  the  angle  of  the  mouth.  The  result  is  shown  in  fig.  130. 

A  month  later,  a  more  extensive  operation  was  made,  to  level  the  mouth  and  to  adjust 
the  relation  of  mouth  to  nose  :  the  lower  nose  was  freed  from  bone,  and  swung  to  the  right. 
and  the  upper  lip  to  the  left,  both  being  sutured  in  their  new  position.  Though  the  nose 
pointed  somewhat  rightward,  yet,  viewed  with  the  mouth,  it  gives  a  more  symmetrical  face. 

A  right  chin  flap  was  then  swung  up  to  the  upper  lip,  to  deepen  it,  and  was  lined  by 
an  advancement  of  mucosa.  As  usual,  this  flap  depressed  the  angle  of  the  mouth  slightly, 
a  defect  not  hard  to  overcome. 

An  effort  was  first  made  to  raise  the  angle  by  a  horizontal  incision  through  all  thick- 
nesses of  the  lip  opposite  the  seat  of  the  depression,  sewn  up  vertically.  This  resulted 
in  a  partial  improvement  of  the  deformity,  and  is  a  method  not  often  indicated.  Two  and 
a  half  months'  rest  was  given,  during  which  massage  and  movements  were  undertaken. 
The  diagram,  fig.  13,  shows  the  method  of  curing  the  depression  of  the  angle  of  the  mouth, 
and  is  in  reality  a  partial  replacement  of  the  original  flap.  A  satisfactory  result  of  this  is 
shown  in  the  final  photograph.  All  scars  were  fading  rapidly  when  the  patient  was  dis- 
charged, and  the  total  eflect  was  gratifying. 


INJURIES    OF    THE    UPPER    LIP 


91 


Fio.  128. — Incisions.  Fid.  129. — Suture. 

The  clotted  area  represents  a  mucous  membrane  flap. 


Fid.   130.— First  result. 


FIG.  131. — Shows  method  of  curing  a  depressed  angle 
of  mouth.   Xote:  this  condition  had  occurred  owing  to 
an  operation  referred  to  in  the  text  but  not  illustrated. 


Flo.  132. — Final  result. 


92  PLASTIC   SURGERY 

CASE   21 

This  case  is  one  of  a  very  similar  character  to  the  last,  and  about  the  same  amount 
of  the  upper  lip  remained  after  the  injury.  The  denture  fitted  to  represent  the  pre-maxilla 
is  shown  in  the  accompanying  figure,  No.  133.  This  case,  treated  on  similar  lines  to 
No.  17,  has  not  shown  the  same  satisfactory  results.  The  lip  was  made  too  short,  and 
considerable  difficulties  were  experienced  in  fitting  a  satisfactory  denture  after  the  new 
lip  had  been  made.  The  probable  reason  why  this  case  has  not  done  so  well  as  the 
previous  one  is  that  there  was  less  mucous  membrane  remaining  after  the  injury. 
Trouble  was  also  experienced  in  retaining  the  denture,  and  adhesions  formed  between 
the  new  lip  and  the  remains  of  the  upper  jaw.  There  were  also  adhesions  to  contend  with 
between  the  cheek  and  the  lower  jaw,  which  made  the  dental  treatment  more  difficult. 
In  this  case  it  would  have  been  wiser  to  use  a  skin  flap,  turned  inwards,  to  line  the  new 
lip.  It  will  be  noted  that  an  ascending  flap  was  not  available  on  the  right  side  on 
account  of  the  scar  tissue  there.  A  modified  descending  flap  was  therefore  used  on  both 
sides,  and  that  on  the  right  had  a  bend  in  it  which  turned  it  in  to  an  advancing  flap. 
The  patient  had  erysipelas  about  six  weeks  after  receiving  his  wound.  The  first 
operation  was  undertaken  about  three  months  after  the  date  of  his  injury.  This  was 
performed  on  9.10.16,  when  adhesions  tying  down  the  nose  were  divided  and  scar  tissue 
excised  ;  about  £  in.  of  the  red  margin  on  the  left  side  was  intact.  A  flap,  including  this 
portion  of  the  lip  as  its  base,  was  cut  from  the  left  side  of  the  nose  and  brought  down 
under  the  nose.  A  skin  and  tissue  flap  from  the  right  side,  with  its  base  opposite  the 
mouth,  was  cut  and  straightened  out  to  meet  the  corresponding  flap  from  the  other  side. 
A  mucous  flap  from  the  inside  of  the  right  cheek  was  cut  with  its  base  on  the  lower  lip  and 
curled  around  part  of  the  new  upper  lip.  A  hare-lip  condition  was  thus  left,  but  it  was 
not  deemed  advisable  to  form  a  double  mucous  flap.  No  relaxation  sutures  were  used, 
but  several  silk-worm-gut  deep  stitches  were  inserted.  There  appears  to  be  some  tension. 


Fio.  133. — Denture  with  artificial  pre-maxilla. 

Examination  of  the  condition  after  this  operation  showed  that  the  new  mucous  lining 
to  right  half  of  upper  lip  was  satisfactory.  There  was  a  U-shaped  gap  in  the  middle  of 
the  upper  lip,  and  no  columella.  On  2.11.16  an  excision  of  the  scar  was  made  round 
the  U,  and  prolongation  of  the  incisions  laterally  on  the  left  through  the  angle  of  the  mouth 
and  through  the  line  \  in.  above  it,  and  through  all  the  layers  of  the  lip  ;  this  was  brought 
over  to  the  right  and  sutured  into  position  with  catgut  and  horsehair  sutures.  The 
columella  of  the  nose  was  formed  by  cutting  out  the  anterior  portion  of  the  remains  of 
the  septum ;  in  this  upper  part  the  knife  was  entered  behind  and  brought  forward  towards 
the  tip,  and  this  made  a  satisfactory  columella,  which  was  inserted  into  the  incision  of  the 
upper  lip.  In  spite  of  careful  suturing  the  left  angle  of  the  mouth  drooped.  Adhesions 
were  divided  between  the  lower  jaw  and  mucous  membrane  on  the  right "  side.  The 
attachmsnt  of  the  new  columella  broke  down,  but  otherwise  the  results  are  fairly  satis- 


INJURIES    OF    THE    UPPER    LIP 


93 


factory.  Great  difficulties  were  experienced  in  keeping  the  lip  well  supported  with  the 
denture,  and  adhesions  reformed.  I  think  the  flap  on  the  right  in  the  original  operation 
should  have  been  taken  right  through  to  the  mucous  membrane  instead  of  making  two 
flaps,  one  of  skin  and  muscle  and  one  of  mucous  membrane.  The  appearance  after  these 


Fia.  1 34. — On  admission  two  months  after 
injury. 


FIG.  135. — Healed.  The  dental  appliance 
displaced  to  show  its  composition.  Note 
the  scar  on  right  cheek  referred  to  in  text. 


FIQ.  130. — Flaps.     (A  mucous  membrane  flap  not  outlined.) 

Diagrams  by  H.  T. 


Fio.  137. — Suture. 


PLASTIC   SURGERY 


FIG.  138. — Result  first  two  operations. 
Note  droop  of  angle :  denture  not  in  place. 


FIG.  139. — Flap  to  raise  angle. 


FIG.  140.— Suture. 


FIG.  141. — Result  of  this.     Denture  fitted. 


INJURIES    OF    THE    UPPER    LIP 


95 


two  operations  is  shown  in  the  accompanying  fig.  138.  The  falling  in  of  the  lip  without 
the  denture  and  the  droop  of  the  left  corner  of  the  mouth  is  well  seen.  A  small  operation 
was  performed  on  13.3.17  in  order  to  raise  the  corner  of  the  mouth,  and  this  was 
successful  in  carrying  out  this  object.  In  order  to  fit  the  denture  in,  Captain  Rumsey 
divided  the  upper  sulcus. 

Scar  tissue  formation,  however,  gradually  filled  up  this  sulcus,  and  prevented  the 
further  wearing  of  the  denture.  In  addition,  trismus  was  present,  which,  on  investigation, 
was  found  to  be  due  to  a  band  of  scar  tissue  from  upper  to  lower  jaw  on  the  right  side 
of  the  cheek,  and  which  had  formed  as  a  result  (a)  of  the  injury,  and  (b)  of  the  intra-oral 
operations. 

On  9.1 .18  an  operation  to  remedy  these  defects  was  undertaken,  the  principle  being 
that  of  the  Esser  epithelial  inlay. 

To  repair  the  upper  sulcus,  an  incision  was  made  at  the  upper  border  of  the  upper 
lip  and  carried  down  to  the  mucous  surface.  Care  was  taken  to  excise  a  portion  of  the 
scar  band  above  mentioned.  The  cavity  produced  was  of  some  size,  and  extended  from 
just  to  the  right  of  the  scar  band  to  where  the  sulcus  became  normal  again  on  the  left 
side  of  the  mouth.  The  usual  Stent  model  and  skin  graft  was  inserted. 

A  similar  procedure  was  carried  out  along  the  lower  sulcus.  The  models  were  taken 
out  on  the  tenth  day  through  intra-buccal  incisions. 

Considerable  difficulty  was  experienced  in  keeping  the  newly  epithelialised  cavities 
patent,  and,  as  the  upper  sulcus  was  the  more  important  of  the  two,  it  received  more 
attention.  The  successful  establishment  of  this  sulcus  was  to  a  great  extent  due  to  the 
careful  efforts  of  Captain  Kelsey  Fry,  M.C.,  R.A.M.C.  The  lower  sulcus  operation  was 
not  so  successful.  It  would  have  been  better  to  have  done  this  at  a  separate  operation. 

The  upper  lip  is  now  maintained  in  a  forward  position. 

On  4.6.18  the  columella  was  re-made  in  a  manner  similar  to  the  first  procedure 
but  of  a  greater  length,  so  that  the  tip  of  the  nose  was  even  .pushed  up  a  little  bit  by  this 
new  columella. 


FIG.  142. 


Final  after  Esser  inlays  and  columella  operation. 


96 


PLASTIC   SURGERY 


CASE  151 

This  is  one  of  the  Australian  patients  who  have  been  under  my  care.  He  was  wounded 
in  the  later  battle  of  the  Somme,  and  came  to  me  at  Aldershot,  six  days  after  receiving 
his  wound  on  20.10.16. 

The  condition,  when  healed,  showed  a  considerable  loss  of  the  pre-maxilla,  and  the 
floor  of  the  nose  in  its  anterior  part,  while  the  soft  tissue  loss  consisted  of  about  two-thirds 
of  the  upper  lip,  together  with  the  left  ala,  columella,  and  anterior  portion  of  the  septum 
of  the  nose.  The  tip  of  the  nose  was  dragged  down  by  fibrous  tissue  and  loss  of  support. 

The  first  operation  was  undertaken  on  March  3rd,  1917.  It  was  of  an  orthodox 
type,  and  consisted  of  two  lateral  nasal  descending  flaps,  A  B  and  A  B.  These  were 
whole-thickness  flaps  which  contained  the  mucous  membrane.  That  on  the  left  proved 
to  be  satisfactory  as  it  contained  the  remaining  normal  part  of  the  upper  lip,  but  that 
on  the  right  contained  much  scar  tissue,  and  the  result  was  not  gratifying. 

Diagrams  representing  the  next  stage  are  appended,  and  the  details  of  this  operation 
follow  : 

The  main  principles  of  it  were,  in  regard  to  the  nose,  that  two  higher  lateral  nasal 
flaps  were  tucked  in  beneath  the  alse  to  allow  the  tip  of  the  nose  to  rise.  And  in  regard 
to  the  right  half  of  the  lip,  it  was  deepened  and  reconstituted  by  turning  downwards  a 
flap  of  skin  as  a  lining  and  the  superimposition  of  a  long  pedicled  bridge  flap  from  the 
left  cheek  and  chin. 

When  this  case  was  transferred  under  Lieutenant-Colonel  Newland,  D.S.O.,  A.A.M.C., 
he  very  kindly  allowed  me  to  continue  the  treatment,  and  I  have  had  the  encourage- 
ment of  his  advice  and  assistance  in  this  somewhat  long  and  difficult  procedure.  The 
case  is  not  yet  completed,  but  is  well  in  hand,  and  the  final  result  should  repay  one  for 
the  efforts  and  length  of  time  expended  on  the  case. 


FlO.  144. — Six  days  after  wound. 


FIG.  145, — When  healed. 


FIG.  J4G. — Side  view. 
Same  stage. 


INJURIES    OF    THE    UPPER    LIP 


97 


Copy  of  Case  Sheet  Notes  given  below  : 

10.3.17.  Operation.— An  upper  lip  was  formed  by  cutting  a  flap  from  right  cheek 
and  swinging  it  down  to  meet  a  similar  one  from  the  left ;  but  this  latter  contained  normal 
mucous  membrane. 


FIG.  147. — Showing  descending  flaps. 


Fia.  148. — Suture. 


Fio.  149. — Result  of  lirst  operation. 


The  tip  of  the  nose  was  freed  and  nasal 
passages  restored.  Tissue  representing  remains 
of  columella  was  dissected  up  and  sutured  to 
middle  line  of  lip.  Small  mucous  flap  was 
turned  up  from  lower  lip  to  form  red  line  for 
remainder  of  upper  lip.  Deep  catgut  sutures 
were  used,  and  artificial  plate  was  inserted 
to  support  new  lip.  Nasal  plugs,  supported 
by  vulcanite  head  piece,  were  adjusted  with  the 
object  of  holding  tip  of  the  nose  in  position. 

20.9.17.  Condition.  —  Previous  operation 
for  upper  lip  moderately  successful.  Con- 
siderable deficiency  middle  of  right  half  of 
upper  lip.  Deformity  of  nose  partially  cor- 
rected, but  columella  has  not  become  attached. 

20.9.17.  Operation.  —  For  correction  of 
upper  lip.  Owing  to  the  scarred  and  pustular 
condition  of  the  face,  no  flap  was  available 
from  the  right  for  the  lip.  In  order  further  to 
raise  the  right  ala,  a  small  flap  was  taken 
from  the  lateral  aspect  of  the  nose  and  swung 
down  beneath  the  ala.  A  similar  flap  was 
swung  down  on  left  side  beneath  the  remains 
of  the  left  ala  and  sutured  to  the  top  of  the 
upper  lip.  This  enabled  the  tip  of  the  nose  to 
be  considerably  raised. 


98 


PLASTIC   SURGERY 


A  skin-flap  of  the  existing  right  portion  of  the  upper  lip  was  turned  downwards, 
with  its  skin  surface  inwards,  and  into  this  raw  area  was  laid  the  end  of  an  ascending 
pedicle  bridge  flap  with  its  base  opposite  the  upper  lip  on  the  left  side.  The  area  from 
which  this  flap  was  taken  was  completely  sewn  up.  The  grafted  end  of  this  flap  obtained 
linn  union  into  the  upper  lip  and  the  pedicle  of  the  flap  was  cut  under  local  amrsthetic  on 
October  13th.  No  attempt  at  replacing  the  pedicle  was  made,  and  it  was  cut  short  at  its 
base.  This  free  lump  of  skin  was  left  sticking  out  from  the  lip  for  possible  future  use  in 
the  nose.  Massage  was  employed  from  the  first  day. 

24.10.17. — Condition  satisfactory.  It  is  possible  to  train  this  flap  of  skin  upwards 
towards  the  nose  for  later  attachment  there. 

Operation  (Major  Gillies  with  Lieutenant-Colonel  Ncwland). — The  cut  pedicle 
referred  to  above  had  rounded  itself  off  into  what  looked  like  a  tip  of  a  nose  lying  on  the 


FIG.  1 50. — 1  ncision  for  inverting  portion  of  lip  to 
complete  the  lining 


FIG.  151. — Diagram  showing  bridge  pedicle  flap  A. 
Terminal  portion  only  used. 


upper  lip.  It  was  partially  re-detached,  and  sewn  up  underneath  the  columella  and  left 
ala.  Lip  support  was  made  by  Captain  Russell,  A.D.C. 

4.2.18.  Operation  (Major  Gillies  with  Lieutenant-Colonel  Newland). — Further  de- 
tachment from  lip  and  completion  of  right  half  of  columella. 

16.5.18.  Operation  (Major  Gillies  with  Lieutenant-Colonel  Newland). — The  left  side 
of  columella  and  lining  of  nostril  was  made,  and  the  remainder  of  flap  was  used  to  form 
the  left  ala. 

20.12.18.  Operation  (Major  Gillies). — Cartilage  taken  from  rib  and  inserted  through 
the  columella  in  two  pieces,  one  down  the  columella  and  one  up  the  bridge.  The  bridge 
piece  was  fixed  at  its  upper  end  to  the  existing  nasal  cartilage  through  a  separate  incision 
made  across  the  bridge  at  a  spot  where  an  existing  scar  was  present.  Result — satisfactory. 
Hut  owing  to  the  pustular  condition  of  the  face,  which  has  continued  despite  special  treat- 
ment, a  slight  infection  of  the  cartilage  occurred.  No  material  damage,  however,  eventuated, 
and  the  sinus  rapidly  healed. 


INJURIES    OF    THE    UPPER    LIP 


99 


FIG.  152. — The  pedicle  cut  near  the  base  and 
allowed  to  curl  up. 


FIG.  153. — Utilising  the  pedicle  for  nasal 
restoration. 


FIG.  154. — Result  after  further  adjustment  and 
cartilage  implant  to  nose  and  columella. 


FIG.  155. — Ditto,  side  view. 


100 


PLASTIC   SURGERY 


CASE   245 


This  sergeant  was  admitted  in  a  healed  condition.  There  was  partial  loss  of  the 
pre-maxilla,  and  loss  of  more  than  half  of  the  upper  lip,  together  with  an  iigly  twisting 
of  the  nose,  and  depression  of  the  tip.  This  patient  was  operated  on  four  months  after 
the  receipt  of  his  wound.  It  will  be  noticed  in  the  appended  operation  notes  that  he 
developed  bronchitis  after  the  operation.  Therefore  the  failure  to  get  a  really  satis- 
factory result  may  well  be  put  down  to  this  trouble,  as  the  coughing  which  followed 
undoubtedly  prejudiced  the  union  of  the  flaps.  Three  weeks  after  this  operation  the 
patient,  when  at  a  Convalescent  Hospital,  developed  septic  pncuziionia,  from  which  he 
recovered  slowly. 

Although  the  record  number  is  a  late  one,  this  was  one  of  my  early  cases,  and  it  brought 
home  to  me  the  necessity  for  some  different  form  of  anaesthesia  from  that  usually  employed 
in  mouth  cases,  and  in  those  of  chin  and  upper  lip  in  particular.  In  the  pages  on 
anaesthesia  this  matter  is  fully  dealt  with.  A  fairly  satisfactory  result  was  obtained 
from  an  aesthetic  point  of  view,  and,  functionally,  it  was  good.  It  should  be  remarked, 


FIG.  150. — Condition  on  admission — healed. 
Loss  o£  right  half  of  lip. 

however,  that  a  secondary  deformity  of  the  lower  lip  was  produced.  Since  the  date  on 
which  the  last  illustration,  fig.  161,  was  taken,  this  sergeant  has  done  a  year's  duty  witli 
Home  troops.  Details  of  operations  on  this  case  follow : 

22.6.16.  Operation. — Formation  of  upper  lip.  The  flap  of  skin  and  mucous  mem- 
brane representing  the  remains  of  the  upper  lip  was  dissected  out  from  left  nostril,  and 
by  an  incision  parallel  to  the  lip  margin  the  flap  was  brought  over  towards  the  right  to 
meet  two  flaps  from  the  right  side  which  were  separated  by  a  piece  of  excised  scar.  The 
lower  of  these  flaps  was  a  small  one,  containing  the  angle  of  the  mouth.  Result  :  The 
dental  shield  for  the  new  lip  which  had  been  made  was  not  tolerated  by  the  patient,  who 
had  some  bronchitis  after  the  operation.  A  certain  amount  of  breaking  down  occurred 
at  the  junction,  and  owing  to  the  absence  of  intra-oral  apparatus  the  new  lip  became 
adherent  to  the  alveolus  of  the  upper  jaw.  Apparatus  for  distending  of  lip  after  division 


INJURIES    OF    THE    UPPER    LIP 


101 


of  adhesions  is  shown  in  photograph.  Three  minor  operations  were  carried  out  to  widen 
the  mouth  and  to  produce  a  mucous  membrane  line  to  the  upper  lip.  Functionally  the 
result  was  good,  cosmctically  there  was  still  an  ugly  arrangement  of  the  lower  lip.  Dis- 
charged for  duty,  3.3.17. 


FIG.  157. — Advancing  flaps. 


FIG.  1 58. — Result,  flat  lip. 


FIG.  159. — Suture. 


FIG.  100. — Attempt  to  bring  forward  and  stretch 
new  lip. 


FIG.  161. — Result  of  later  operations.  Denture 
fitted.  Note :  the  lip  is  still  flat  and  has  no 
central  prominence.  The  lower  lip  is  pouting. 


102 


PLASTIC   SURGERY 


CASE   4.3 

These  cases  of  upper  lip  arc  dealt  with  here  in  order  of  decreasing  severity,  and  this 
one  shows  a  loss  which  is  less  than  the  previous  one.  The  result  is  correspondingly  better. 
In  addition  to  an  upper  lip  injury,  there  was  a  slight  deformity  of  the  lower,  combined 
with  loss  of  the  angle.  The  condition  within  forty-eight  hours  of  the  wound  is  shown  in 
the  first  illustration,  and  I  am  indebted  to  Major  Valadier,  C.M.G.,  for  allowing  me 
to  have  the  early  wound  record  of  this  case.  The  second  photograph  is  an  illustration  of 
the  result  of  an  early  suture,  performed  by  Major  Valadier  in  France.  The  mucous  mem- 
brane of  the  upper  lip  was  preserved  by  sewing  it  to  the  chin,  and  the  tag  on  the  cheek 
was  sutured  into  place,  the  mucous  membrane  being  also  brought  out  to  the  skin  edge. 
This  system  undoubtedly  helps  the  later  plastic  repair  as  it  decreases  the  scar  tissue. 
Accompanying  this  injury  was  a  very  large  loss  of  bone  in  the  lower  jaw,  involving  the 
angle  and  adjacent  portions  of  the  mandible ;  there  was  also  a  considerable  loss  of  bone 
in  the  superior  maxilla  and  alveolar  process.  The  further  method  of  repair  is  illustrated 
in  the  accompanying  diagrams,  and  consisted  in  a  whole  thickness  flap  swung  down  from 
the  left  lateral  nasal  region  to  meet  the  remains  of  the  upper  lip  which  was  split  to 
receive  it,  the  lower  portion  of  the  split  containing  the  vermilion  border  being  made  to 
extend  along  the  new  portion  of  lip. 

To  complete  the  mucous  membrane,  that  of  the  lower  lip  was  swung  round  the  corner 
to  the  upper,  a  slight  advancing  of  the  flap  marked  "  B  "  enabled  the  lower  lip  to  be  satis- 
factorily corrected.  No  further  operations  on  the  lip  were  undertaken,  and  a  satisfactoiy 
result  was  produced.  Discharged  to  duty. 


Kio.  162. — Shortly  after  wound.     Taken  in  France  (Valadier). 


INJURIES    OF    THE    UPPER    LIP 


103 


FIG.  163. — On  admission — healed. 


Fio.  104. — Descending  and  ascending  whols 
thickness  flaps. 


FIG.  105. — Suture. 


Fia.  100. — Result. 


Fio.  107. — Same  later. 


104 


PLASTIC   SURGERY 


FIG.  108. — Prior  to  admission  to  Queen's  Hospital. 


FIG.    109. — On  admission  healed.      Part  loss  of 
upper  lip,  nose,  and  cheek. 


CASE  324 


This  is  included  in  this  series  as  an  example  of  the  use  of  a  temporal  and  scalp  flap  for 
the  external  covering  of  a  portion  of  the  upper  lip.  One  half  of  the  upper  lip  remained  on 
the  left  side,  the  right  half  being  completely  absent,  as  well  as  a  large  portion  of  the  cheek, 
nose,  and  right  superior  maxilla ;  there  was  an  accompanying  fracture  of  the  right  mandible, 


FlO.  170. —  A  and  B  are  interned  epithelial         FIG.  171. — E  the  temporal  flap 

flaP8-  sutured  to  form  the  covering.  Fl(J  ,  -2  _Result  after  return  of  temporal 

flap.     Note  deficiency  of  upper  lip,  and  of 
contour. 


INJURIES    OF    THE    UPPER    LIP 


105 


with  deformity  of  contour.  The  patient  was  transferred  to  this  hospital  eleven  months  after 
being  wounded.  The  mandible  had  united  by  approximation.  The  first  operation  was 
undertaken  as  a  combined  lip,  nose,  and  cheek  plastic.  In  fig.  170,  flaps  A  and  B  were 
turned  skin-surface  inwards  to  form  a  lining  for  the  right  ala  and  right  half  of  the  upper 
lip.  The  latter  was  sutured  to  the  mucous  membrane  on  the  back  of  B,  which  is  the  re- 
maining portion  of  the  upper  lip.  Over  the  raw  area  thus  produced  a  shaped  flap,  E,  from 
the  right  temporal  region  was  sutured  into  position  on  24.9.17.  Three  weeks  later  the 
pedicle  of  flap  E  was  returned.  This  was  done  for  me  by  Captain  C.  F.  Rumsey,  R.A.M.C., 
and  the  result  of  these  two  operations  is  shown  in  the  next  fig.  172.  Considerable  time  was 
allowed  to  elapse  during  which  cpilation  by  X-rays  of  the  hairy  surface  of  the  nose  was 
undertaken.  As  the  new  upper  lip  was  too  shallow,  it  was  decided  to  turn  skin  surface 
inwards  a  portion  of  this  new  flap  and  to  bring  up  an  ascending  flap  from  the  right  side 
of  the  chin,  and  at  the  same  time  a  flap  of  mucous  membrane  was  brought  up  from  the 
lower  lip  for  a  vermilion  border. 

Rhinoplasty  was  performed  on  18.11. 18,  and  at  this  operation  the  pedicle  of  the  mucous 
membrane  flap  of  the  previous  operation  was  divided  to  form  the  right  corner  of  the  mouth. 
When  the  pedicle  of  the  rhinoplasty  was  returned  a  depressed  scar,  caused  by  the  ascending 
lip-flap,  was  excised,  and  a  notch  in  the  new  upper  lip  was  corrected  by  a  Rose  operation 
(Captain  Ferris  N.  Smith,  R.A.M.C.).  Cartilage  was  inserted  over  the  right  mandible  and 
further  scars  excised  on  3.2.19.  Present  result  is  shown. 


Fro.  173. —  1.  Deepening  the  lip  by  an  ascend- 
ing chin  flap. 

2.  Mucous  membrane  flap  from  lower  to  upper 
lip. 

3.  Preliminary  to  radical  nasal  reconstruction. 


FIG.  174. — Final  result  of  lip,  cheek,  and  nose 
plastics.  Note  the  improved  cheek  contour  by 
cartilage  graft. 


10(5 


PLASTIC   SURGERY 


CASE   143 

There  arc  several  interesting  features  about  this  case  which  need  defining.  I  have 
included  it  in  the  "  Upper  Lips,"  as  I  have  learned  a  principle  in  connection  with  its  repair. 
It  is  also  one  of  my  first  cases.  I  designed  the  upper  lip  operation  with  two  superimposed 
flaps  so  as  to  produce  depth  at  the  spot  where  the  hare-lip  type  of  notch  was  present. 
Tin-  two  flaps  were  made  to  overlap  after  the  replacement  of  the  vermilion  border  to 
its  normal  level.  A  good  deal  was  allowed  for  contraction,  and  the  right-hand  flap  was 
cut  in  such  a  \\ay  as  to  produce  considerable  drooping  of  the  right  half  of  the  upper  lip. 


Fio.  1 75. — Hnre-lip  type  of  deformity  with 
loss  of  substance. 


FIG.  1 70. — Scar  excision. 


Fio.  177. — Scheme  of  the  flaps. 


FIG.  1  "8. — Diagram  of 
overlapping  flaps  to  pro- 
duce depth. 


FIG.  179. — Result  of  Jip  operation.     Xote 
redundancy. 


INJURIES    OF    THE    UPPER    LIP 


107 


There  was  no  important  loss  of  the  mucous  membrane  lining  of  the  upper  lip,  and 
consequently  the  retraction  and  contraction  following  the  operation  was  very  limited. 
Therefore  I  had  to  excise  portions  of  this  flap  until  the  correct  level  of  the  vermilion 
border  was  obtained.  Another  principle  involved  in  this  repair  was  to  use  pointed 
overlapping  flaps  to  produce  depth. 

In  regard  to  the  nose  plastic,  the  scar  running  down  the  right  aspect  of  the  nose  and 
across  the  bridge  was  excised ;  the  nose  was  raised  and  the  right  ala  was  sewn  down  at  a 
lower  and  normal  level.  This  was  done  on  the  occasion  of  the  second  operation.  A  month 
later  a  bone  graft  was  taken  from  the  left  tibia  and  inserted  into  the  bridge  of  the  nose  to 
raise  it.  The  bone  was  cut  with  the  Albce  double  electric  saw.  The  periosteum  was  not 
included.  In  regard  to  the  fixation,  the  periosteum  over  the  glabella  region  was  raised 
and  a  groove  made  into  the  bone  into  which  the  upper  end  of  the  graft  was  fixed.  The 
distal  end  of  the  graft  was  pushed  down  subcutaneously  into  a  cavity  made  for  it  nearly 
as  far  as  the  tip  of  the  nose.  A  misfortune  occurred 
at  the  end  of  this  operation,  as  the  patient  vomited 
freely  before  the  graft  was  quite  fixed  in  position 
and  the  asepsis  of  the  field  of  operation  was  thereby 
violated.  A  slight  suppuration  followed,  but  this 
practically  cleared  up  except  for  an  occasional  drop 
of  pus  which  could  be  squeezed  out.  Later  a  small 
portion  necrosed  and  was  taken  away  from  near  the 
left  internal  canthus.  The  skin  then  healed  up 
satisfactorily,  but  no  bony  union  occurred  with  the 
frontal  bone.  When  last  examined,  the  graft  was 
still  in  position,  but  is  presumably  in  process  of 
being  replaced  by  fibrous  tissue,  and  the  bridge  had 
not  been  sufficiently  raised.  It  was  decided,  there- 
fore, to  insert  some  cartilage,  which  was  done 
through  an  incision  over  the  tip  of  the  nose  and 
into  the  columella.  A  piece  of  costal  cartilage 
was  then  superimposed  over  the  remains  of  the 
bone  graft.  When  in  position,  the  extremity  of  the 
cartilage  was  bent  into  the  tissues  of  the  columella 
to  support  the  tip.  The  incision  over  the  bridge 
of  the  nose  was  likewise  reopened  at  this  operation, 
and  an  attempt  was  made  to  get  union  with  the 
frontal  bone  by  turning  down  an  osteo-periostal 
flap  beneath  the  original  bone  graft.  Whether 
bony  union  occurred  or  not  was  not  established  as 
the  patient  was  discharged  to  duty,  but  the  cartilage  operation  was  satisfactory  in  every 
way  except  at  the  bridge  of  the  nose,  where  it  became  slightly  displaced.  As  far  as  the 
left  eyelids  are  concerned,  mal-union  of  the  upper  lid  had  occurred,  completely  obliterating 
the  palpebral  fissure.  This  upper  lid  was  freed  by  a  mesial  descending  incision,  and  the 
lid  was  sewn  up  at  a  higher  level.  The  lower  lid  was  also  freed  by  carrying  a  curved 
incision  from  the  inner  angle  outwards  beneath  the  lower  lid,  and  this  also  was  sewn  at  a 
higher  and  more  mesial  position.  A  moderate  amount  of  vision  remained  in  the  left 
eye,  and  considerable  benefit  accrued  to  the  patient  by  reopening  his  palpebral  fissure 
both  in  regard  to  appearance  and  function.  The  final  result  is  shown  in  fig.  ISO.1 


FIG.   1 80. — Excision  of  excess  lip  and  nose  and 
eyelid  plastics. 


1  This  is  the  only  case  in  which  I  have  used  bone  alone  for  raising  the  bridge  of  the  nose.     Compare 
this  case  with  case  252,  p.  228. 


108  PLASTIC   SURGERY 


CASE   48 

Another  type  of  upper  lip  is  shown  in  the  following  case.  The  patient  was  received 
after  many  plastic  operations  in  the  condition  shown  in  fig.  181,  and  there  was  a  large  muss 
of  scar  tissue  making  up  the  substance  of  the  upper  lip.  There  was  a  blob  of  mucous 
membrane  at  the  left  corner,  which  was  utilised  by  extending  it  along  to  the  right.  The 
patient  was  edentulous.  This  also  was  one  of  my  early  cases.  The  result  of  the  first 
operation  is  shown  in  the  second  picture.  The  main  feature  of  this  operation  was  the 
excision  of  the  scar  which  was  present  in  the  upper  lip  and  around  the  depressed  angle  of 
the  mouth.  This  left  a  very  large  gap  to  be  filled  in,  which  difficulty  was  met  by  a  descend- 
ing flap  from  the  left  cheek.  The  flap  united  satisfactorily  in  its  new  position,  but  the 
suture  of  the  cheek  after  the  removal  of  the  flap  broke  down  somewhat  badly,  as  is  evident 
in  the  photograph.  A  subsequent  operation  was  performed  to  widen  the  mouth,  but  this 
had  to  be  curtailed  owing  to  anaesthetic  difficulties  and  blood  collecting  in  the  patient's 
throat.  The  scar  of  the  face  was  excised,  but  again  this  broke  down.  I  decided,  therefore, 
to  give  him  a  prolonged  course  of  X-ray  treatment,  massage  and  special  vaccine  made 
from  culture  of  his  own  micro-organisms.  An  attempt  was  again  made  to  excise  the  ugly 
scar  on  the  left  cheek;  but,  as  on  previous  occasions,  this  broke  down,  but  only  partially. 
The  total  result  was  a  very  considerable  improvement  in  appearance  and  function. 


INJURIES    OF    THE    UPPER    LIP 


109 


FIG.  181. — Large  portion  of  upper  lip  occupied  by 
keloidal  scar. 


FIG.  182. — Note  breaking  down  of  secondary 
suture  area,  after  the  descending  lateral  nasal  flap 
had  been  brought  down  to  upper  lip. 


Fio.  183. — Final  result. 


no  PLASTIC   SURGERY 


CASE   242 

This  case  shows  an  injury  of  the  lip  without  serious  bony  damage,  with  less  of  teetli 
only.  The  loss  of  the  lip  is  a  little  more  than  a  third,  but  the  loss  of  the  skin  surface  is 
greater  than  that  of  the  mucous  membrane.  The  condition  when  it  had  healed  is  shown 
in  the  next  illustration,  which,  however,  does  not  adequately  represent  the  amount  of  scar 
tissue  to  be  excised.  The  morphology  of  the  original  wound  was  therefore  reproduced, 
but  to  a  slightly  diminished  extent.  The  diagram  illustrates  the  amount  of  scar  tissue 
which  had  to  be  excised  and  the  flaps  used  to  repair  it.  It  should  be  remarked  that 
the  vermilion  border  b?longing  to  the  right-hand  flap  was  separated  from  this  flap  and 
advanced  on  to  the  lower  border  of  the  left-hand  flap,  so  that  the  skin-joint  was  not  at 
the  same  site  as  that  of  the  mucous  membrane.  In  criticising  the  result  of  this  procedure, 
which  was,  in  general  terms,  a  descending  flap  and  partly  an  advancement  method,  it 
will  be  observed  that  the  upper  lip  slightly  overhangs  the  lower  at  the  left-hand  corner 
of  the  mouth,  and  the  lower  lip  is  somewhat  pushed  out  of  position  thereby.  This,  I 
think,  is  due  to  the  advancement  of  the  flap,  and  bears  out  my  contention  that  the 
upper  lip  will  stand  little  in  the  way  of  shortening  by  advancement  flaps. 


INJURIES    OF    THE    UPPER    LIP 


111 


FIG.  1 84. — One  week  after  injury. 


FIG.  185. — ftesult. — Note  the  overlapping  at  the 
angle  produced  by  an  "  advancement "  flap. 
This  is  amenable  to  secondary  correction,  but 
only  the  one  operation  was  performed  in  this 
case. 


FIG.  ISO.— Excision  and  Incision.  No  mucous 
membrane  was  excised,  as  might  bo  inferred  from 
diagram. 


FIG.  187.— Suture.     Note  skin  and  mucous 
membrane  suture  at  different  sites. 


112  PLASTIC   SURGERY 


CASE  177 

This  private  was  received  after  a  gunshot  wound  which  had  destroyed  half  the  skin 
of  the  upper  lip  and  one-third  of  the  veimilion  border.  He  was  admitted  into  the  depait- 
msnt  in  the  scarred  and  healed  condition  as  shown  in  fig.  188,  and  had  already  received 
two  or  three  plastic  operations  on  the  lip.  The  amount  of  loss  of  tissue  is  well  shown  in 
the  diagram,  representing  the  healthy  tissue  remaining  after  excision  of  the  scar  tissue 
in  the  upper  lip.  The  scar  tissue  in  the  cheek  was  similarly  excised.  Under  chlorofoim 
oxygen  anaesthesia,  in  the  sitting  position,  the  scar  tissue  in  the  upper  lip  was  excised  com- 
pletely, except  where  it  had  involved  the  mucous  membrane  on  the  posterior  suifacc.  A 
large  ascending  flap  from  the  cheek  was  taken  to  fill  up  this  gap,  as  illustrated  in  dia- 
gram 189,  and  the  mucous  membrane  surfaces  readjusted.  The  healing  was  by  first 
intention,  but  the  result  of  the  operation  was  to  depress  the  corner  of  the  mouth.1  This 
was  due  to  the  base  of  the  pedicle,  flap  "  A"  being  too  wide.  Another  secondary  deformity 
occurred  as  a  result  of  this  operation  on  3.4.17  in  that,  in  drawing  the  two  cut  surfaces  of 
the  mucous  membrane  together,  an  unpleasant  pouting  of  the  corner  of  the  mouth  was 
produced.  On  3.9.17  operation  was  again  performed,  the  objects  of  which  were  to  restore 
the  left  angle  of  the  mouth  to  its  proper  level,  to  evert  the  mucous  membrane  and 
to  attempt  to  thicken  the  border  of  the  lip.  In  the  first  place,  a  reverse  flap  to  that 
taken  at  the  original  operation  was  swung  from  the  upper  to  the  lower  lip  to  correct  the 
level  of  the  corner  of  the  mouth.  This  flap  was  not  as  big  as  is  shown  in  diagram 
190,  and  it  should  be  noted  that  it  runs  across  the  scar  line  of  the  first  flap,  and  is  in  reality 
a  partial  replacement  of  the  original  flap.  This  manoeuvre  was  quite  successful,  as  usual, 
in  restoring  the  level  of  the  corner  of  the  mouth.  In  regard  to  the  eversion  of  the  mucous 
membrane  of  the  upper  lip,  an  arrow-head  piece  of  skin  was  excised,  as  shown  in  the 
diagram ;  the  edges  when  sewn  up  produced  a  satisfactory  eversion  of  the  mucous  mem- 
brane. To  make  this  border  more  prominent,  the  subcutaneous  fat  and  muscle  from 
the  upper  part  of  the  lip  was  dissected  from  above  downwards,  and,  whilst  still  partially 
attached,  was  rolled  down  as  a  flap  of  tissue,  which  was  then  sutured  into  the  free  border, 
the  method  of  which  was  by  mattress  sutures,  as  indicated  in  the  diagram,  fig.  191.  The 
result  of  this  procedure  was  quite  definite  in  producing  a  prominence  of  the  border  of  the 
lip,  and  the  aesthetic  result  was  satisfactory.  Functionally,  it  was  quite  good,  except 
that  the  mouth  was  not  sufficiently  large.  But,  as  the  patient  was  quite  satisfied,  he  was 
discharged. 

1  See  also  Case  7,  pagci  90,  for  method  of  avoiding  this  droop  of  the  corner  by  excision  of  part  of 
the  natural  lip. 


INJURIES    OF    THE    UPPER    LIP 


113 


FIG.  1  89. — Excision  of  scar  and  ascending  flap. 


FIG.  188. —Healed  condition. 


Fio.  1 90. — Correction  for  depression  of  angle  of  mouth. 


FIG.  191. — Scheme  to  show  arrow-head  excision  of  skin, 
and  method  of   rolling  down  the  soft  tissues  of  the  lip 
to  its  edge,  to  produce  prominence  and  presentation  of 
the  vermilion  border. 
8 


FIG.  192.— Result. 


114 


PLASTIC   SURGERY 


CASE   295 


Is  that  of  an  officer  in  the  Field  Artillei  y.  who  was  struck  by  a  shell  on  September  27th, 
1916.  He  was  admitted  nine  months  later  for  plastic  treatment  in  the  condition  shown 
in  the  first  illustration.  A  large  depressed  scar  ran  horizontally  across  his  check,  ending 
in  various  small  scars  in  the  remains  of  the  right  half  of  the  upper  lip.  The  underlying 
loss  of  bone  comprised  the  major  portion  of  the  right  upper  alveolar  process  and  antciior 
wall  of  the  right  antrum.  The  mucous  membrane  loss  was  practically  nil,  whereas  the 
skin  of  half  the  upper  lip  had  been  shot  away,  the  vermilion  border  being  drawn  up  by 
the  scar  tissue,  producing  a  marked  ectropion.  The  right  corner  of  the  mouth  was 
normal,  and  the  question  of  supplying  the  necessary  amount  of  skin  to  cure  this  deformity 
presented  many  difficulties.  Had  I  used  an  ordinary  imbedded  ascending  flap,  the  corner 
of  the  mouth  would  undoubtedly  have  been  seriously  displaced,  necessitating  further 
correcting  operations.  Descending  flaps  were  contra-indicated  on  account  of  the  scar 
tissue  and  no  hair  being  thereon.  Two  further  designs  presented  themselves  to  me,  both 
of  the  ascending  flap  variety,  the  first  of  which  necessitated  excising  the  already  existing 
corner  of  the  mouth,  so  as  to  imbed  the  flap,  and  it  was  therefore  discarded  ;  the 
remaining  method,  which  was  the  one  adopted,  was  to  use  an  ascending  flap,  but  to 
imbed  only  the  terminal  portion  of  it,  thus  making  it  into  a  bridge  flap,  the  pedicle 
lying  over  healthy,  untouched  skin.  The  vermilion  border  was  carefully  preserved  and 
resutured,  as  is  shown  in  the  intermediate  stage  illustrations.  The  under  raw  surface 
of  the  bridge  was  protected  by  waxed  gauze,  while  two  silk-worm  sutures  were  passed 
through  the  vermilion  surface  of  both  lips,  at  the  right  corner,  in  order  to  steady  the 
parts  and  to  prevent  oral  secretions  reaching  the  wounds.  The  return  of  the  pedicle 
was  carried  out  on  7.9.17,  i.e.  on  the  eleventh  day  the  bridge  of  the  flap  was  cut  in  a 
slanting  direction  just  clear  of  where  it  had  been  sutured  into  the  upper  lip,  and  the 
remaining  free  end  of  the  graft  was  sutured  into  place.  The  pedicle  of  the  bridge  was 
re-fitted  into  the  check,  and  in  doing  this  a  small  amount  of  granulation  tissue  had  to  be 
cut  away  before  the  pedicle  was  replaced  into  its  original  position.  It  should  be  noted 
that  the  under  surface  of  the  bridge  was  kept  exceedingly  clean,  No.  7  Ambrine  wax  dressing 
being  used.  The  result,  so  far  as  the  moustache  and  upper  lip  arc  concerned,  was  all  that 
one  could  desire,  and  at  the  second  stage  of  the  operation  a  small  portion  of  the  redundant 
mucous  membrane  was  excised.  As  to  the  reinsertion  of  the  pedicle,  I  doubt  whether  any 
advantage  has  accrued.  Owing  to  the  slight  granulations  on  its  under  surface,  there  was 
a  distinct  tendency  at  first  to  present  a  somewhat  rounded  appearance ;  but,  although  this 
has  subsided,  there  was  no  necessity  to  preserve  this  piece  of  skin  in  this  particular  case, 
and  the  resulting  scar-line  might  have  been  better  than  it  is. 

In  regard  to  the  depression  of  the  check  and  the  long  scar,  a  dental  apparatus — 
designed  by  Sir  Francis  Farmer — has  materially  aided  in  bulging  out  the  cheek  ;  but 
this  did  not  fill  up  the  hollow  in  the  cheek.  A  considerable  free  fat  graft  was  successfully 
implanted  under  the  skin  at  a  later  stage,  but  the  result  of  this  is  not  illustrated. 


Fio.  193. — Illustrating  "  bridge  "  pedicle  flap  for  upper  lip  and  moustache. 


INJURIES    OF    THE    UPPER    LIP 


115 


FIG.    194. — The  healed  condition  nine  months  after 
wound.     Ectropion  from  loss  of  skin  surface. 


FIG.  1 95.— Bridge  pedicle  flap  in  position. 


Flo.  190. — Pedicle  returned.     Moustache  grown, 


Fio.  1 97. — Ditto.  Note :  the  hollow  in  the  cheek 
was  filled  by  a  free  fat  graft  and  excision  of 
scar  at  a  later  stage. 


116 


PLASTIC   SURGERY 


CASE  270 

This  case  of  a  minor  injury  of  the  upper  lip  is  included  for  one  or  two  reasons.  It 
was  due  to  the  exit  wound  of  a  bullet  which  entered  behind  the  right  angle  of  the  mandible, 
which  it  broke,  passed  through  into  the  month,  and  carried  a  few  of  the  front  teeth  through 
the  upper  lip.  The  blow  in  this  case  was  very  severe,  and  the  officer  told  me  that  he  felt 
as  if  the  whole  of  the  face  had  been  shattered.  There  is  no  important  loss  of  tissue,  but 
the  method  of  repair  is  interesting  as  an  illustration  of  the  value  of  overlapping  flaps  in 
producing  depth.  The  wound  had  caused  the  stellate  explosion  of  the  upper  lip,  and  when 
the  case  was  sufficiently  healed  to  conic  for  operation,  six  weeks  after  the  battle  of  the 
Somme,  it  presented  a  somewhat  similar  appearance  to  that  shown  in  the  illustration 
which  was  taken  in  the  semi-healed  condition.  The  diagrams  accompanying  this  record 
indicate  how  each  radiation  of  the  scar  was  excised,  and  the  little  flaps  thus  outlined  were 
each  prolonged  by  incision  to  a  slight  extent  and  then  interlocked  the  one  above  the 
other.  Comparing  this  case  with  that  of  143  and  others  in  section  on  lower  lips,  the 
value  of  this  method  of  producing  depth  at  the  place  one  most  wants  it  is,  I  think,  estab- 
lished. The  second  illustration  is  that  of  the  condition  just  after  the  removal  of  the 
stitches  and  the  scar  lines  are  plainly  visible.  When  this  officer  returned  to  duty,  he  sent 
me  a  photograph  taken  by  an  ordinary  lay-photographer ;  the  growth  of  the  moustache 
has  effected  a  perfect  result. 


Fio.  1 98. — Exit  wound  of  bullet.     Semi-healed 
condition. 


INJURIES    OF    THE    UPPER    LIP 


117 


Fict.  1 99. — Exoision  and  Incision 


FIG.  200.— Suture. 


Fia.  201.— On  removal  of  stitches. 


FIG.  202. — Result.—  Photo  taken  by  lay 
photographer. 


118  PLASTIC  SURGERY 


CASE  179 

This  is  a  very  atypical  deformity  of  the  upper  lip  caused  by  a  gunshot  wound,  received 
on  August  18th,  1916,  details  of  which  are  lacking  owing  to  the  fact  that  the  patient  was 
not  admitted  to  me  until  March  1st,  1917,  in  the  healed  condition  shown. 

The  scar  near  the  angle  of  the  mouth  produced  a  very  marked  deformity  of  the  upper 
lip,  and  this  case  is  not  so  much  one  of  a  restoration  as  it  is  one  of  a  deformity.  The  interest 
of  the  case,  I  think,  revolves  round  the  principle  with  which  such  condition  should  be  treated. 
The  method  actually  used  is  very  clearly  shown  in  the  diagrams.  The  large  descending 
flap,  A,  from  the  cheek,  was  swung  down  beyond  the  corner  of  the  mouth,  after  excision 
of  all  scar  tissue.  The  natural  flap,  produced  by  excision  of  the  scar,  was  stretched 
upwards  and  backwards.  The  marked  eversion  of  the  vermilion  border  was  very  satis- 
factorily cured,  and  the  gain  of  tissue  necessary  to  maintain  this  result  was  obtained  at. 
the  expense  of  the  tissue  beneath  the  left  eye,  and  the  tension  of  this  flap,  which  would 
have  a  natural  tendency  to  recede  upwards,  was  taken  from  the  flap,  B,  which,  being 
attached  to  the  lower  lip,  prevented  any  late  alteration  in  the  replaced  upper  lip. 

The  photograph  of  the  result  was  taken  seven  weeks  after  operation. 


INJURIES    OF    THE    UPPER    LIP 


119 


FIG.  203. — Nine  months  after  wound. 


Fio.  204. — Excision  and  flaps.     Flap  B  referred  to 
in  text  is  that  just  below  A. 


Fio.  205. — Suture.  Flap  .1 '  brought  down  to 
a  lower  lip  attachment  at  A.  B  (not  marked) 
swung  backwards. 


FIQ.  200. — Result  seven  weeks  after  operation. 


LOWER  LIP  AND  BONE-GRAFTING    OF 

MANDIBLE 


CHAPTER    IV 
INJURIES    OF    THE    LOWER    LIP    AND    CHIN 

THIS  chapter  includes  injuries  to  the  lower  lip,  certain  injuries  involving  both 
lips  and  leading  to  conditions  of  contracted  mouth,  and  injxvries  to  the  soft 
and  hard  tissues  of  the  chin. 

The  injuries  to  the  lower  lip  are  arranged  roughly  in  order  of  increasing 
severity.  There  is  a  certain  definite  group  which  may  be  termed  the  Hare 
Lip  type,  in  which  a  satisfactory  repair  may  be  obtained  by  a  simple  advance- 
ment of  the  remaining  portions,  the  aesthetic  and  functional  results  varying 
directly  with  the  amount  of  tissue  lost.  When  more  than  one-third  of  the 
lower  lip  is  missing,  the  result  of  the  advancement  repair  ceases  as  a  rule  to 
be  satisfactory.  It  sometimes  happens  that  the  resulting  diminished  lower 
lip  fits  in  well  with  the  loss  of  bony  chin. 

But  in  planning  all  repairs  of  the  lower  lip,  .the  first  thought  of  the  surgeon 
must  be  to  provide  a  satisfactory  bed  for  a  denture,  with  a  buccal  orifice  of 
such  a  size  as  will  admit  the  necessary  temporary  or  permanent  appliance. 

In  the  group  of  injuries  leading  to  microstoma  no  account  is  taken  of  facial 
burns,  which,  in  the  author's  opinion,  are  by  far  the  commonest  cause  of  the 
condition.  Another  important  cause  that  should  be  here  mentioned  is  inex- 
perienced surgical  procedure,  such  as  omission  to  provide  a  lining  membrane 
for  flaps. 

Injuries  to  the  chin  naturally  divide  themselves  into  those  of  the  soft  tissues 
only — in  which  good  functional  and  aesthetic  repair  is  the  rule — and  those 
involving  loss  of  bone.  In  those  terrible  cases  in  which  the  whole  of  the  mandible 
from  molar  region  to  molar  region  is  carried  away,  the  author  has  neither  seen 
nor  performed  any  series  of  operations  which  may  be  said  to  have  achieved 
more  than  mediocre  result  as  regards  appearance  and  more  than  a  very  pool- 
result  as  regards  function.  The  condition  is  one  analogous  to  loss  of  a  limb, 
and  in  the  upshot  a  presentable  appearance  is  often  the  mask  of  a  skeleton  of 
surgical  inefficacy. 

The  most  serious  difficulty  in  the  way  of  functional  repair  is  the  provision 
of  a  depressor  musculature  for  the  new  jaw.  One  has  several  times  seen  what 

123 


PLASTIC    SURGERY 

appeared  to  be  a  moderately  satisfactory  repair,  including  a  successful  bone- 
graft,  prove  wcllnigh  worthless  from  lack  of  attachment  of  the  suprahyoid 
muscles  and  platysma.  Little  or  no  excursion  of  the  mandible  occurs,  and 
there  remains  a  gross  impairment  of  speech  and  of  the  first  stage  of  deglutition. 
It  should  be  noted  that  the  remaining  fragment  of  the  mandible  assumes  a 
position  determined  by  the  removal  of  the  muscles  opposing  the  internal  ptery- 
goid,  temporal,  and  external  ptcrygoid  muscles,  as  well  as  of  the  support  afforded 
by  its  continuity  with  the  condyle  of  the  opposite  side.  It  is  therefore  swung 
upwards,  forwards  and  inwards,  and  somewhat  protruded,  and  when  the  patient 
tries  to  open  his  mouth,  the  deformity  is  merely  accentuated. 

In  the  attempt  to  provide  a  depressor  musculature,  in  one  case,  in  which 
all  idea  of  the  formation  of  a  bony  chin  had  been  abandoned  in  favour  of  an 
intrabuccal  dental  appliance,  the  author  dissected  out  and  epithelialised  what 
remained  of  the  anterior  belly  of  the  digastric. 

The  idea  was  to  introduce  it  into  the  floor  of  the  mouth,  with  a  view  to 
attaching  it  to  the  denture  by  means  of  an  artificial  tendon  after  the  manner 
of  Putti.  But  the  exigencies  of  the  service,  and  in  the  urgent  necessity  of 
making  the  major  repairs  in  this  case,  prevented  the  fulfilment  of  the  plan. 

There  is,  moreover,  in  these  cases  a  total  lack  of  control  of  the  lower  lip. 
The  author,  in  the  attempt  to  relieve  this,  uses  descending  nasolabial  flaps 
which  include  some  muscular  fibres  with  nerve  supply  intact.  These  continue 
to  function  in  their  new  position,  and,  by  tightening,  effect  some  degree  of 
closure  of  the  buccal  orifice. 

The  simplest  and,  fortunately,  the  most  common  injury  of  the  lower  lip 
is  of  the  hare-lip  variety,  which  requires  for  its  repair  excision  of  the  scar,  com- 
bined with  accurate  resuture,  and  advancement  or  elevation  of  the  tissues. 

Where  the  lesion  occurs  near  the  corners  of  the  lower  lip  it  is  the  common 
practice  to  advance  the  tissue  situated  laterally  to  the  scar.  The  point  of  the 
chin  in  these  cases  is  usually  in  its  normal  position,  and  so  the  gain  of  tissue 
that  is  required  is  obtained  from  the  lateral  aspect  after  excision  of  the  scar. 

A  few  cases  illustrating  this  deformity  are  appended. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


125 


Case  50  shows  a  lesion  of  the  lower  lip  in  the  same  region  as  in  the  previous  cases, 
with  ectropion  from  scar  tissue  contraction.  The  diagram  illustrates  the  method  by 
means  of  which  the  ascending  flap  was  swung  up  to  fill  in  the  gap  and  to  raise  the  lip. 
No  special  point  is  to  be  noted  in  this  case  except  that  flap  A  was  inserted  between  the  lip 
and  the  chin,  and  flap  A  being  wedge-shaped,  the  more  it  was  drawn  in  between  them  the 
more  the  lip  was  raised. 


FIG.  207. — Healed  condition.     (Note  ectropion  of  lip.) 


FIG.  208. — Excision  of  scar  and  freeing  of  flap. 


FIG.  209.— Suture. 


FIG.  210.— Result. 


126  PLASTIC    SURGERY 


CASE  244 

This  case  was  wounded  in  Mesopotamia  by  a  bullet  which  entered  into  the  left  super- 
ciliary margin,  and  after  perforating  the  bone  there,  re-entered  it  just  below  the  left  eye, 
perforating  also  the  left  antrum  and  palate,  and  then  carried  through  the  lower  jaw  and 
left  side  of  the  lower  lip. 

The  external  wounds  were  healed  on  admission  to  the  Cambridge  Hospital,  Aldershot, 
and  the  mandible,  after  sequestrotomy  and  extraction  of  involved  teeth,  united.  The 
palate  was  also  replaced  by  a  dental  appliance,  under  the  supervision  of  Captain  L.  A.  B. 
King,  R.A.M.C. 

The  lower  lip  was  treated  in  the  following  manner  :  The  loss  of  tissue  being  trifling, 
the  scar  was  freely  excised  and  adhesion  to  the  mandible  freed.  Three  natural  flaps  were 
thus  outlined,  and  the  two  lateral  ones  advanced  in  the  V  Y  fashion.  The  mucous  membrane 
was  treated  separately  and  specially,  so  as  not  to  get  depression  at  the  point  of  union.  The 
vermilion  border  attached  to  the  left  corner  of  the  mouth  was  dissected  back  to  the  corner 
along  the  muco-cutaneous  junction  ;  that  on  the  main  portion  of  the  lip  was  similarly  divided 
along  the  muco-cutaneous  border  until  it  could  be  easily  advanced  to  the  left  corner  of  the 
lip,  where  it  was  resutured.  Its  upper  border  was  then  freshened,  and  the  little  flap  attached 
to  the  left  corner  sutured  into  this  freshened  area.  The  advantage  of  this  method  of  dealing 
with  the  mucous-membrane  suture  is  that  the  union  of  the  two  halves  of  the  vermilion 
border  is  on  a  different  vertical  plane  from  that  of  the  skin,  and  there  is  no  tendency  to 
a  dimple  at  the  junction. 

Two  of  the  photographs  illustrating  this  case  are  of  pastel  drawings  by  Professor  Henry 
Tonks,  the  ordinary  negatives  not  being  available. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


127 


j 


— ••-. 


Fio.  211. — Healed  condition. 


Fio.  212. — After  operation. 


•Mucous  flap 
turned  back 
Raw  surface  shaded 
to  meet  similar 
raised  surface  on  A- 


FIG.  213. 


1-28  PLASTIC    SURGERY 


CASE  58 

was  a  Royal  Flying  Corps  officer,  who  was  wounded  by  seven  machine-gun  bullets,  at  Kut, 
in  Mesopotamia.  The  wound  that  is  here  illustrated  was  caused  by  one  of  the  bullets. 

There  was  a  loss  of  mandible  of  about  one  and  a  half  inches  in  the  right  prc-molar  region. 
The  dense  scar  in  this  region  extended  up  to  the  vermilion  border  of  the  lip,  which  was 
dragged  down  with  it.  The  scar  was  of  a  radiating  character,  and,  on  excision,  it  was  found 
that  the  free  portion  of  the  lip  came  back  into  position  easily,  but  in  order  to  fill  up  the 
large  gap,  caused  by  the  excision  of  the  scar,  with  healthy  tissue,  it  was  necessary  to  make 
a  swinging  advancement  of  the  cheek  in  the  neighbourhood.  This  is  illustrated  in  the 
diagram,  and  is  visible  in  the  photograph  showing  the  result.  This  flap  also  prevented  a 
tendency  to  eversion  of  the  lip  on  the  one  hand,  and,  on  the  other,  to  the  displacement  of 
the  soft  tissues  of  the  chin  to  the  right,  which  would  have  occurred  had  a  straight  "  sew-up  " 
been  attempted. 

This  officer  was  submitted  to  a  bone-graft  operation  seven  months  after  being  wounded, 
and  four  months  after  the  plastic.  The  bone-graft  was  eminently  successful,  and  notes  of 
this  operation  and  of  X-rays  follow  : 

17.3.17.  Operation  (Captain  Gillies). — Ends  of  bone  cut  down  upon  and  isolated  from 
adherent  tissues,  and  inferior  dental  canal  in  both  fragments  reamed  out.  A  gap  of  one  inch 
separated  the  fragments.  A  rib-graft  was  taken  from  right  thorax  with  periosteum  attached 
on  outer  surface,  with  an  overlap  of  about  half  an  inch  at  each  end.  The  extremities  of 
graft  were  pointed  and  these  points  engaged  in  reamed-out  canal  of  fractured  ends  of  man- 
dible. Wound  sutured  with  horsehair.  Drainage  (gut).  Wound  healed  by  primary 
intention. 

23.4.17. — X-ray  shows  bone-graft  in  excellent  position.  Much  callus  being  thrown 
out  around  its  posterior  anchorage. 

February  1919.— Examined  by  the  judging  committee  of  the  Odontological  Section 
of  the  Royal  Society  of  Medicine,  and  pronounced  to  have  firm  bony  union  and  90  per  cent, 
function. 

This  and  the  preceding  cases  had  no  serious  shortage  of  the  mucous  membrane. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


129 


FIG.  214.— Healed  condition. 


Fm.  215. — Excision  of  scar  and  advancement 
of  cheek  flap. 


9 


Fio.  216—  Suture. 


FIG.  217.— Result. 


PLASTIC    SURGERY 


The  next  cases  are  examples  of  injuries  to  the  corners  of  the  mouth,  and 
do  not  exactly  belong  to  either  the  Upper  or  Lower  Lip  group. 

CASE  5 

In  Case  5  a  large  piece  of  shell  entered  at  one  angle  of  the  mouth  and  eame  out  through 
the  opposite  side,  fracturing  the  mandible  and  tearing  away  the  adjacent  portions  of  the 
cheek.  This  patient  was  wounded  on  July  1st,  1916,  and  fig.  218  shows  the  rendition  on 
admission  two  days  after  being  hit.  Unfortunately,  a  graphic  record  of  his  healed  condition 
was  not  taken.  The  X-rays  showed  fracture  of  the  mandible  in  two  places — in  the  region 
of  the  first  molar  tooth,  and  in  the  region  of  the  symphysis,  the  intermediate  portion  of 
bone  being  displaced. 

Plastic  operation  was  undertaken  on  September  llth,  1916,  and  consisted  in  excision 
of  scars  on  both  sides. 

On  the  right  side  the  two  surfaces  of  the  cheek  were  merely  drawn  together,  and  the 
mucous  membrane  from  the  inside  of  the  mouth  brought  out  to  form  a  new  angle  (fig.  219). 

On  the  left  side,  a  combined  skin  and  mucous  membrane  flap  was  swung  towards  the 
oral  opening  both  in  the  upper  and  lower  lips  (vide  figs.  219  and  220). 


FIG.  218. — Early  condition. 


Fio.  219.— First  plastic.     Excision  and  suture. 


The  result  of  this  operation  was  satisfactory,  except  that  the  movement  of  the  lower 
jaw  began  to  stretch  the  line  of  union  of  the  flaps  on  the  right  side  of  the  cheek,  and  the 
wound  partially  broke  down  near  the  corners  of  the  mouth  (fig.  221).  It  was  limited  by 
immediately  fitting  a  closely  applied  chin-splint  and  attaching  it  over  the  head.  Since 
then,  in  all  eases  in  this  region,  I  have  been  careful  to  support  the  lower  jaw  until  the  opera- 
tion wound  is  well  healed. 

Second  plastic  operation  (October  31st,  1916).  Scar  re-excised,  and,  in  order  to  raise 
the  corner  of  the  mouth  a  little,  a  flap  was  outlined  as  per  diagram  (fig.  223)  and  sutured  to 
the  lower  lip. 

Third  plastic  operation  (January  1st,  1917).  A  portion  of  the  right  scar  having  again 
broken  down,  it  was  re-excised,  the  knife  being  used  obliquely  to  the  skin  surface.  Local 
iat-flaps  were  turned  in  from  above  and  below  the  depression,  sutured  together  with  catgut, 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


131 


and  the  skin  sewn  over  this  pad  with  fine  interrupted  horsehair.  A  small  mucous  membrane 
correction  was  made  on  the  left  upper  lip,  and  the  left  lower  lip  was  raised  at  the  corner  by 
sewing  up  perpendicularly  a  horizontal  incision  through  the  whole  thickness  of  the  lip 
(fig,  224). 


FIG.  221.— After  first  plastic. 


FIG.  222. — Final. 


FIG.  223.— Second  plastic. 


FIG.  224. — Method  used  to  raise  lower  lip. 


Figs.  218,  222  and  221  show  the  condition  before  and  ; after  treatment,  and  the  stage 
after  the  first  operation. 

Firm  bony  union  of  the  lower  jaw  has  occurred,  and  the  patient  can  eat  solid  food. 
Further  improvement  could  be  effected  by  bringing  down  the  upper  lip  at  the  left  angle. 

The  dental  work  was  carried  out  by  Captain  F.  E.  Sprawson,  R.A.M.C. 

The  diagrams  illustrating  the  operations  were  drawn  by  Professor  Henry  Tonks. 


I.T2  PLASTIC    SURGERY 


CASE  563 

Probably  at  the  time  of  injury  this  was  a  similar  type  to  that  of  Case  5,  but  a  less 
serious  wound. 

The  mouth  had  healed  well,  but  with  a  marked  microstoma,  which  was  a  functional 
disability.  There  were  also  disfiguring  scars  at  the  corners  of  the  mouth. 

Previous  history  was  not  obtainable,  and  the  only  interest  in  the  case  is  that  of  the 
widening  of  the  buccal  orifice.  A  thin,  triangular  portion  of  skin  and  scar  tissue  was 
excised  at  each  angle  of  the  mouth.  The  mucous  membrane  was  well  divided  in  the  middle, 
and  then  sutured  to  the  skin. 

The  improvement  in  the  microstoma  was  very  marked,  and  the  appearance  was  quite 
satisfactory,  although  the  photograph  of  the  final  condition  was  taken  without  the  presence 
of  dentures. 

I  include  this  case  because  I  think  a  slightly  better  appearance  is  obtained  when  a 
small  portion  of  the  skin  and  subcutaneous  tissue  is  excised  to  allow  the  mucous  membrane 
to  curl  round  and  show  itself. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


133 


I 


FIG.  225. — Healed  condition. 


Fio.  226. — Microstoma  relieved. 


PLASTIC   SURGERY 


Three  cases  of  loss  of  the  central  portion  of  the  lower  lip  are  next  discussed. 

In  two  of  these  the  condition  seen  after  wounding  is  represented  photo- 
graphically, and  in  one  of  them  (Case  62)  the  healed  stage  is  available. 

I'nfamiliarity  with  this  class  of  injury  leads  one  to  think  that  the  material 
loss  is  very  much  greater  than  it  actually  is. 

CASE  62 

Corporal  C ,  was  admitted  on  6.7.16,  five  days  after  being  wounded,  with  fracture  of 

the  jaw  in  the  symphysis  region  and  loss  of  the  middle  third  of  the  lip. 

When  the  bone  condition  had  been  successfully  controlled  and  the  sequestra  had  all 
come  away,  a  plastic  operation  was  performed  for  me  by  Lieutenant  Dixon,  R.A.M.C., 
with  the  assistance  of  Lieutenant  C.  B.  Tudehope,  R.A.M.C.,  and  after  excision  of  the  scar, 
which  went  down  to  the  bone,  the  flap  on  the  right  was  swung  upwards  and  to  the  left, 
while  that  on  the  left  was  undercut  and  raised. 

The  new  lower  lip  was  considerably  shorter  than  his  original  one,  but  is  sufficiently 
satisfactory  from  both  cosmetic  and  functional  points  of  view. 


Flo.  227. — On  admission. 


FiG.228. — Healed  condition. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


135 


FIG.  229. — Excision  of  Scar :  flaps  outlined. 


Fio.  230. —  After  first  plastic. 


FIG.  231. — Final  after  excision  of  scar. 


130 


PLASTIC   SURGERY 


CASE  256 

Another  type  treated  by  excision  of  scar, 
and  raising  of  the  halves  of  the  lip,  is  also 
illustrated. 

Note  the  apparent  seventy  of  the  lip 
injury,  which  is  obviously  a  photographic 
effect. 

The  operation  notes  are  : 

Private  Mc.H ,  admitted  19.8.16. 

Condition. — Slight  loss  of  tissue  of  lower 
lip  with  the  two  halves  firmly  united  to  man- 
dible and  presenting  a  V-shaped  gap. 

29.9.16.  Operation  (Lieutenant  Tude- 
hopc). — Type  freeing  of  lip-halves  and  pro- 
longation of  the  incision  lateralwards  to  allow 
necessary  depth  on  resuture. 

Result. — Satisfactory.  Slight  scarring. 
Discharged,  duty,  7.2.17. 


FIG.  222. — Early  condition. 


Fio.  233.— Healed  condition. 


Fid.  234.— After  lip  plastic. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


137 


CASE  205 

This  is  another  simple  type  giving  satisfactory  result. 

It  was  necessary,  however,  very  carefully  to  adjust  the  mucous  membrane  on  the  inner 
side  of  the  flap. 

The  jaw  was  in  process  of  uniting,  and  an  artificial  set  of  teeth  was  fitted  over  the 
splint  (Captain  L.  A.  B.  King,  R.A.M.C.),  to  enable  the  plastic  to  be  more  accurately  per- 
formed. 


FIG.  235. — Healed  condition. 


FIG.  236.— After  plastic. 


138 


PLASTIC   SURGERY 


The  following  two  cases  show  clearly  the  loss  of  the  lip  and  its  red  margin, 
reparable  by  a  forward-swung  mucous  membrane  flap.  In  each  case  the  skin  and 
subcutaneous  tissue  loss  was  made  good  by  a  descending  flap,  or  flap  of  election, 
taken  from  the  nasolabial  fold. 

CASE  198 

showed  a  elean  loss  of  the  central  third  of  the  free  portion  of  the  lower  lip.  The  scar  having 
been  excised,  the  mucous  membrane  was  advanced  across  the  gap,  and  a  flap  of  suitable 
size,  was  brought  down  from  the  left  of  the  nasolabial  fold,  and  sutured  into  position.  The 
terminal  portion  of  this  flap,  for  an  obscure  reason,  went  blue,  and  was  lost  through  dry 
gangrene.  Perhaps  the  pedicle  of  this  flap  was  a  little  too  small. 

The  result  after  the  operation  wound  had  healed  as  shown  in  the  second  photograph, 
and  presents  an  ugly  scar  and  notch  in  the  middle  line.  Later,  this  was  excised,  and  by  a 
VY  double  swinging  advancement  a  deep  and  satisfactory  lip  was  obtained. 


FlO.  237.— On  admission. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


139 


'&:.   Mucous  flap  from 
inside  of  cheek. 


FIG.  238. — Steps  in  first  plastic. 


Fia.  239.— After  Orst  plastic. 


FIG.  240.— Final  plastic. 


140 


PLASTIC    SURGERY 


CASE  8 

Tlie  mucous  membrane  shown  in  Professor  Tonks's  pastel  (photo  represented)  was 
carefully  preserved  by  stitching  it  to  the  skin  margin  in  the  early  stages  of  this  man's  wound. 

\Ylten  the  large  wound  on  the  right  side  of  the  check  had  healed,  a  plastic  operation 
was  undertaken  for  me  by  Lieutenant  C.  B.  Tudehope,  R.A.M.C.  The  corner  of  the  mouth 
had  been  dragged  down  by  the  sear,  and  was  relieved  by  its  excision.  In  order  to  improve 
the  position  of  the  corner  of  the  mouth  and  maintain  it  at  a  correct  level,  a  descending 
flap  from  the  right  nasolabial  fold,  containing  skin  and  subcutaneous  tissue,  was  swung 
down  and  sutured  beneath  the  readjusted  vermilion  border.  A  pleasing  effect  was  thereby 
produced,  but  it  might  have  been  possible  to  raise  the  centre  of  the  lip  a  shade  more  by 
making  the  flap  a  little  longer. 


Fio.  241.— Early  condition. 


FIG.  242.— After  plastic. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


141 


CASE  243 

This  needs  little  explanation.  Not  only  were  the  two  lateral  flaps,  A  and  A',  advanced 
and  swung  upwards  in  the  V  Y  fashion,  but  the  apex  of  the  V  was  itself  raised  by  suture  to 
the  deep  tissues.  The  result  is  suffieiently  satisfactory.  The  bone  lesion  was  one  of  con- 
siderable comminution,  and  the  case  healed  with  a  pseudarthrosis  in  the  mandible.  This 
was  treated  by  excision,  and  inlay  of  an  osteo-periosteal  graft  from  the  tibia,  with  the 
result  that  bony  union  occurred.  Five  months  after  the  bone  operation  the  patient  was 
discharged  to  duty. 


FIG.  243. — Healed  condition. 


FIG.  244. — Excision  of  scar  and  delimitation  of  flaps. 


^f 


Via.  245. — Suture. 


Fia.  240.— Result. 


1  I'-' 


PLASTIC   SURGERY 


CASE  45 

Graphic  records  of  the  condition  on  the  tenth  day  after  wound  and  after  the  parts 
became  soundly  healed  are  given. 

The  loss  of  tissue  comprised  the  left  half  of  the  lip  in  all  its  layers,  the  shortage  of 
mucous  membrane  being  considerable. 

The  method  of  plastic  repair  consisted  of  a  descending  nasolabial  flap  for  the  skin  and 
muscular  layers,  combined  with  an  advancement  flap  of  the  mucous  membrane. 

The  result  was  fairly  satisfactory  from  the  cosmetic  point  of  view,  but  there  is  no  doubt 
that  the  mucous  membrane  was  still  very  short,  and,  owing  to  adhesion  between  the  new 
lower  lip  and  cheek  and  the  mandible  on  the  left  side,  the  fitting  of  an  artificial  denture 
became  a  serious  difficulty.  This  was  subsequently  remedied  by  an  epithelial  inlay  by 
KSMT'S  method,  with  moderately  good  functional  result. 

•  I  think  the  mucous  membrane  difficulty  in  this  case  might  have  been  better  met  in 
the  first  instance  by  taking  a  whole-thickness  flap  from  the  nasolabial  region.  An  alternative 
which  would  have  acted  well  would  have  been  to  make  a  new  sulcus  along  the  mandible 
before  undertaking  the  plastic  closure.  Another  way  of  dealing  with  this,  but  requiring 
more  extensive  flaps,  would  have  been  to  turn  in  the  skin  in  the  neighbourhood  of  the 
scar  to  form  the  buccal  lining. 

It  will  be  noted  that  the  nasolabial  flap  was  carried  to  a  point,  the  reason  for  which 
has  already  been  discussed. 


Fio.  247. — Early  condition. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


143 


f 


->^te^- 


FIG.  248. — Healed  condition. 


Fio.  249. — Excision  of  scar  and  delineation  of 
descending  nasolabial  flap. 


FIG.  250.— Suture. 


FIG.  251. — Present  stage. 


144  PLASTIC    SURGERY 

CASE  2 

'1  his  case  is  one  of  interest  and  also  of  partial  failure.     The  interest  lies  in  the  ring-like 
injury  of  the  month. 

The  mucous  membrane  healed  with  great  tendency  to  keloidal  scar  tissue,  and.  despite 
the  persistent  use  of  apparatus,  made  under  the  supervision  of  Captain  L.  A.  B.  King, 
R.A.M.C.,  attempts  to  prevent  the  mouth  contracting  failed,  and  a  marked  condition  of 
mierostorna  was  present  when  the  lips  were  healed.     The  buccal  orifice  was  surrounded  by 
an  unyielding  ring  of  scar  tissue,  giving  a  maximum  width  of  1J  inches.     The  loss  of  tissue 
\\;IN  mainly  in  the  lower  lip,  the  mucous  membrane  of  which  was  entirely  absent. 
Before  plastic  repair,  a  preliminary  excision  of  all  scar  tissue  was  performed. 
In    regard  to  the  upper  lip,  careful  resuture,  combined  with  the  pulling  out  of   the 
mucous  membrane,  gave  a  sufficiently  satisfactory  result. 

For  the  lower  lip,  double  nasolabial  descending  flaps  were  used,  that  on  the  left  being 
longer  than  that  on  the  right.  These  were  taken  down  to  the  muscular  layer  only,  part 
of  which  was  included  in  the  flap.  Such  mucous  membrane  as  was  provided  for  this  lip 
was  taken  from  a  similar  area  to  the  skin-flaps,  but  as  independent  flaps.  The  result  was 
moderate  so  far  as  appearance  is  concerned,  and  the  fault  was  due  to  the  fact  that  there 
was  a  great  shortage  of  the  lining  membrane  of  the  lip  and  of  the  lower  sulcus,  which  pre- 
vented the  fitting  of.  a  satisfactory  lower  denture. 

This  patient  refused  further  treatment  at  the  time,  but  there  is  no  doubt  that  a  most 
satisfactory  functional  and  cosmetic  effect  would  be  produced  by  a  successful  epithelial 
inlay  between  the  gum  and  new  lower  lip.  The  scar  tissue  of  the  lower  lip  had  been  very 
successfully  got  rid  of,  and  the  new  one  was  of  great  softness  and  pliability,  with  a  certain 
amount  of  muscular  movement,  which  made  one  regret  the  inability  to  complete  the  case. 


Flo.  252. — Early  condition. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


145 


Fia.  253. — Healed  condition. 


FIG.  25-t. — Excision  of  scar  and  outlining  of  flaps. 


Fio.  255.— Suture. 


FIG.  250. — Final. 
(I'atient  refused  further  treatment.) 


10 


146 


PLASTIC   SURGERY 


lost. 


The  diagnosis  in  these  injuries  rests  on  the  accurate  estimation  of  the  tissues 


CASE  99 

The  photograph  taken  on  admission  seven  days  after  the  receiving  of  the  wound  shows 
that  the  loss  of  tissue  comprised  the  right  two-thirds  of  the  free  border  of  the  lower  lip, 
together  with  an  injury  of  the  cheek.  The  destruction  of  the  mucous  membrane  does  not 
go  down  to  the  lower  buccal  sulcus  ;  consequently,  the  shortage  of  mucous  membrane  is 
not  so  great  as  it  might  appear  from  examination  of  the  photographic  record.  The  photo 
of  the  healed  condition  is  not  available. 

The  result  of  the  first  operation  was  moderately  good.  The  operation  notes  show  that 
when  the  scar  tissue  was  removed  the  loss  of  tissue  was  roughly  represented  by  what  I  have 
already  described  and  what  was  apparent  before  the  healing  had  commenced. 

Two  swinging  advancement  flaps  were  utilised  to  make  good  the  main  body  of  the  lip, 
while  mucous  flaps  were  able  to  be  cut  and  brought  out  to  remake  the  vermilion  border. 
Subsequent  minor  corrections  were  carried  out  to  overcome  this  shortage,  the  main  one 
of  which  consisted  of  a  flap  of  mucous  membrane,  taken  from  the  upper  lip  and  sewn  to 
the  lower. 

Note. — On  discharge  from  hospital  the  mouth  was  slightly  contracted. 


Fio.  257.— Early  condition. 


Fio.  258.— Excision  of  scar  and  outlining  of  flaps. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


147 


J 


Via.  259.— Suture. 


Fio.  260.— Early  result. 


FIG.  261. — After  minor  corrections. 


148 


PLASTIC    SURGERY 


CASE  137 

Private  W—  -  is  the  only  example  in  this  series  of  cases  in  which  a  combined  skin, 
muscle,  and  mucous  membrane  flap  was  taken  from  the  nasolabial  fold  and  brought  down 
to  make  the  lip.  The  loss  of  tissue  in  the  early  and  healed  conditions  is  shown  in  ligs. 
2(52  and  263.  The  shortage  of  mucous  membrane  was  rather  greater  than  is  apparent. 

This  whole-thickness  flap,  cut  with  square  ends,  was  found  to  be  too  thick  when  brought 
down,  and  the  middle  fatty  layer  was  dissected  out  from  the  outer  and  inner  edges  in  order 
to  reduce  its  thickness.  (See  Professor  Tonks's  diagrams.)  Even  then,  the  lip  was  a  little 
too  fat,  and  bad  suture  lines  spoiled  what  would  otherwise  have  been  a  very  perfect  result. 
The  lip  had  excellent  function,  and  was  very  pliable. 

Diagrams  are  below,  and  the  record  of  the  condition  of  this  man  on  admission  is  a  re- 
production of  one  of  Professor  Tonks's  exceptional  drawings  in  pastel. 


FIG.  2fi2.— Early  condition. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


149 


Fia.  263. — Healed  condition. 


Fio.  204. — Excision  of  scar  and  outlining  of  (lap. 


FIG.  265. — Excision  of  fatty  layer  from  flap. 


FIG.  260.— Suture. 


Fio.  207.— Final. 


PLASTIC   SURGERY 


CASE  184 

This  case  is  one  full  of  interest  in  all  its  stages.  This  gallant  trooper  was  wounded  and 
eaptured  while  on  distant  outpost  duty  in  the  wilds  of  East  Africa.  In  addition  to  a 
fractured  arm  and  loss  of  the  lower  lip,  severe  dysentery  followed  owing  to  insufficient 
medical  care.  He  made  good  his  escape,  and,  after  tramping  through  the  Bush  country 
— a  journey  of  about  150  miles — he  managed  to  get  under  British  medical  treatment. 

lie  had  been  operated  on  twice  by  his  captors  for  his  jaw  condition,  and  on  eventually 
arriving  in  my  clinic  all  wounds  were  healed  and  his  condition  was  as  shown  in  fig.  268.  The 
loss  comprised  the  greater  part  of  the  free  portion  of  the  lower  lip  in  all  its  layers.  A 
stump  of  the  lip  remained,  however,  at  each  corner. 

The  first  operation  was  moderately  success- 
ful, and  its  method  of  gaining  tissue  to  remake 
the  lower  lip  consisted  of  a  partially  descending 
swinging  advancement  from  the  left  cheek,  and 
this  flap  was  drawn  and  sutured  above  the 
existing  chin  skin,  and  the  mucous  membrane 
from  either  side  advanced  over  its  upper  border. 
The  diagram  roughly  represents  its  principle. 

Five  months  later,  the  new  lip  was  in  a  con- 
dition of  entropion,  as  would  be  expected,  the 
mucous  membrane  being  too  short  to  allow  the  lip 
to  be  sufficiently  free.  In  addition,  there  was  no 
inferior  sulcus  on  which  an  efficient  denture  could 
be  carried,  a  condition  which  was  accentuated  by 
the  fact  that  the  alveolar  bone  had  been  de- 
stroyed. It  was  decided  to  employ  the  Esser 
inlay  for  this  entropic  condition,  with  most 
satisfactory  results,  the  date  of  this  operation 
being  21.9.17. 

This  was  the  first  of  its  kind  that  the  author 
had  done,  or  seen  done,  and  it  was  probably  the 
first  case  treated  by  this  method  in  this  country. 
FIG.  208.— Healed  condition.  A  discussion  on  the  matter  with  Major  Waldron 


Fid.  269. — Descending  nasolabial  flap. 


FIG.  270.— Suture. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


151 


FIG.  271. — Condition  after  descending  nasolabial 
flap  operation. 


C.A.M.C.,  who  advised  the  perusal  of  Esser's 
article,  led  to  the  adoption  of  this  means  of 
treating  the  condition. 

An  exceptionally  efficient  denture  was 
now  applicable,  and  in  the  fitting  of  this  the 
patient  had  the  advantage  of  Sir  Francis 
Farmer's  skill. 

Following  the  freeing  of  this  lip  by  the 
Esser  inlay,  the  lip  was  raised  by  a  nasola- 
bial  fold,  taken  from  the  left  side.  A  marked 
bossing  of  this  flap  occurred,  which  diminished 
very  slowly,  and  the  reason  for  this  lymphatic 
stasis  is,  as  yet,  I  think,  an  undiscovered 
factor. 

One  has  not  discovered  the  reason  why 
some  of  these  flaps  show  this  rounding  and 
others  not.  In  this  particular  case,  it  is  pos- 
sible that  the  skin-graft  on  the  inner  aspect 
of  the  lip  had  something  to  do  with  the  ab- 
sence of  drainage  from  the  area. 
In  addition  to  this  being  due  to  lymphatic  blockage,  there  is  undoubtedly  a  certain 
amount  of  fibrosis  which  occurs  in  the  bed  of  the  flap.  For  this  reason,  it  was  decided  to 
operate  again,  and  at  the  same  time  to  get. an  everted  free  margin  of  the  lower  lip.  Incision 
was  made  along  the  line  A  B  in  fig.  272,  which  lay  along  the  existing  muco-cutaneous 
junction.  This  incision  also  was  carried  down  along  the  suture-line  to  the  right,  the  scar 
of  the  suture-line  being  excised.  The  skin  was  then  carefully  undermined,  leaving  the 
subcutaneous  tissue  in  position,  and  this  undermining  was  continued  below  the  lower  scar 
of  the  rounded  flap.  Then  a  large  amount  of  the  subcutaneous  tissue  was  dissected  from 
below  upwards,  and  made  to  lie  between  the  mucous  membrane  and  skin  of  the  original 
incision,  as  shown  in  the  diagram,  D  in  fig.  273.  This  allowed  the  skin  of  the  rounded  flap  to 
go  flat.  Next,  the  now  exposed  fat-flap  D — lying  between  the  skin  and  the  mucous  membrane 
—was  covered  by  mucous  membrane  flap  C  from  the 
upper  lip. 

The  method  of  making  a  vermilion  border  from  one 
lip  to  the  other  is  typified  in  this  case.  I  give  particulars 
of  the  technique  used.  The  upper  lip  was  well  raised 
forward,  and  the  mouth  well  packed  to  prevent  blood 
going  down,  and  incision  was  made  along  the  gingivolabial 
junction  of  the  central  portion  of  the  upper  lip.  Two 
perpendicular  cuts  to  the  free  margin  were  carried  from 
extremities  of  this  incision.  This  mucous  flap,  thus  out- 
lined, was  reflected  from  above  downwards  until  it  well 
covered  the  fat  flap  D  without  tension.  The  sutures 
necessary  to  retain  this  mucous  membrane  flap  were 
now  inserted  without  being  tied  ;  they  consisted  of  one 
relaxation  suture  of  silk-worm  gut  from  the  upper  lip  to 

the    chin,    next    a    row   of    four    horsehair    sutures    was 

'  _  ,      „  FIG.  272. — Incision     along      muco 

inserted   through    the   mucous    nap,    and    lour   mat.ress     cutaneous  junction     (D   the 'dotted 


area,  represents  a  subcutaneous  flap 
which  was  elevated  to  form  a  basis 
for  new  vermilion  border.) 


horsehair  sutures  through  the  mucous  flap  joining  it  to 
the  mucous  membrane  of  the  lower  lip.  These  were  in- 
serted about  \  in.  from  the  free  border  of  the  mucous 
flap,  so  that  sufficient  mucous  membrane  remained  to  go  over  D  to  join  the  skin. 
These  sutures  being  got  into  position,  the  mouth  plugging  was  removed,  and  relaxation 
and  backrow  sutures  were  tied.  It  remained  to  join  the  free  edge  of  the  mucous  flap  to  the 
skin  of  the  lower  lip.  An  anaesthetic  was  given  for  this  operation  by  Captain  J.  C. 


1  .->•_> 


PLASTIC   SURGERY 


Clayton,    R.A.M.C.,    ether,    nasal   tubes,    and    mouth-packing  being  used — a   particularly 
satisfactory  procedure  in  this  case. 

Diagrams  of  this  procedure  and  a  photograph  of  the  lip  in  this  stage  showing  the  back 
row  of  sutures  in  position  accompany  these  notes. 


FIG.  273. — Subcutaneous  fat  flap  (D) 
being  raised  from  chin  region  to  help  form 
lip. 


FIG.  274. — Mucous  flap  from  upper 
lip  outlined. 


Fia.  27C. — Front  view  of  Fig.  275. 


Fia.  275. — Mucous  flap  swung  from 
upper  to  lower  lip. 


Fia.  277. — Mucous  flap  being  sutured  into  place. 
(Note  retention  suture.) 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


153 


The  broad  pedicle  of  this  mucous  flap  was  detached  under  novocaine  ten  days  later. 
Feeding  was  maintained  by  passing  a  tube  through  the  corner  of  the  mouth. 

Owing  to  the  excellent  result,  one  was  encouraged  to  fill  up  the  corners  by  mucous- 
membrane  flaps  from  the  lateral  portions  of  the  upper  lip, 

Anaesthesia  for  this  operation  was  obtained  by  blocking  the  infra-orbital  nerve  at  its 
exit  from  the  canal,  and  by  local  novocaine  infiltration  to  the  lower  lip. 


FIG.  278. — Mucous  flap  from  upper  lip  applied  to 
lower  lip.  (Patient  fed  through  a  tube  in  corner 
of  mouth.) 


FIG.  279. —  Final,  showing  new  vermilion  border 
for  lower  lip. 


PLASTIC   SURGERY 


CASE  188 

A  very  good  result  was  obtained  in  this  case.  The  healed  and  early  conditions 
show  a  loss  of  more  than  half  of  the  lower  lip  through  all  its  thickness,  but  the  tissues 
of  the  chin  are  merely  displaced  in  the  freshly  wounded  condition. 

Only  one  operation  was  done  on  this  lip,  and  by  good  fortune  a  more  than  satisfactory 
result  was  obtained  by  it.  The  main  principle  of  it  was  a  descending  nasolabial  fold- flap, 
which  was  deepened  to  the  muscular  layer  only  and  brought  down  to  meet  the  right  portion 
of  the  lip  remaining,  which  was,  at  the  same  time,  advanced  and  raised.  The  lining  was 
obtained  by  freeing  a  stump  of  mucous  membrane  present  at  the  left  corner  of  the  mouth, 
and  converting  it  by  undercutting  into  a  flap  which  was  advanced  across  the  new  lip  to 
meet  the  existing  vermilion  border  of  the  right. 

A  large  gap  in  the  bone,  some  2|  in.,  now  existed,  and  a  bone-graft  operation  was 
performed  ten  months  after  the  wound.  The  rib-graft  was  wedged  between  the  fragments, 
and  a  bone-peg  was  used  to  fix  the  posterior  end  of  the  graft  to  the  angle  of  the  ascending 
ramus.  The  patient  was  edentulous,  and  the  difficulty  of  the  fixation  of  the  fragments 
was  not  sufficiently  overcome  to  obtain  fixation  of  the  graft.  It  was  noticed  on  the  fourth 
day  that  a  drop  or  two  of  fluid  came  away  from  the  mouth,  which  was  due  to  the  bone-peg 
working  loose  and  perforating  the  mucous  membrane.  Inevitable  suppuration  followed, 
and  the  graft  was  eventually  removed.  Its  place  was,  however,  taken  by  a  strong  ostco- 
fibrous  band,  which  was  of  some  functional  use  to  the  patient,  whose  age  was  thirty-five. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


155 


FIG.  280. — Early  condition. 


FIG.  281.—  Henled  condition. 


FiQ.  282. — After  plastic  and  bone  graft. 


I.-,.;  PLASTIC   SURGERY 


CASE  236 

This  was  a  combined  case  of  Captain  Aymard's  and  the  author's.  This  South  African 
soldier  was  severely  wounded  in  the  lower  lip  and  mandible,  in  the  battle  of  the  Somnie.  The 
healed  condition  is  not  shown.  The  loss  of  tissue  consisted  of  the  central  two-thirds  of  the 
free  margin.  The  natural  flap,  which  is  shown  lying  semi-detached  in  the  first  photograph, 
was  utilised  by  me  in  the  first  operation.  This  natural  flap  was  enlarged  by  incisions  in  the 
downward  direction,  and  maintained  by  deep  catgut  sutures  to  the  periosteum  of  the  surface 
of  the  symphysis.  A  mucous  flap  was  drawn  from  the  left  side  to  cover  a  portion  of  the  lip. 

Captain  Aymard,  K.A.M.C.,  then  undertook  the  completion  of  the  case,  and  by  ad- 
vancement of  flaps,  shown  in  the  diagram,  achieved  a  deepening  and  widening  of  the  lower 
lip,  while  the  mucous  membrane  was  provided  from  the  upper  lip. 

The  appearance  of  tin's  new  vermilion  border  was  distinctly  pleasing. 


.-- 


FlO.  283.— Early  condition. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


157 


x''"- 


Fio.  284. — After  first  "plastic. 


Fia.  285. — Mucous  flap  from  upper  for  lower  lip 
and  skin  flaps  outlined. 


I         I 


Fio.  2SG. — Flaps  swung  and  sutured. 


Fio.  287. — Final. 


158  PLASTIC   SURGERY 


CASE  535 

This  soldier  received  a  shell-wound  of  the  mandible  and  chin.  The  destruction  involved 
the  mandible  to  the  extent  of  some  two  and  a  half  inches  between  the  left  canine  and  the 
right  molar  region  ;  it  involved  the  soft  tissues  over  a  similar  area,  but  the  mucous  membrane 
of  the  left  third  of  the  lower  lip  remained,  and  the  healing  process  extended  downwards 
along  the  raw  edge. 

The  fragments  of  the  mandible  were  maintained  in  a  good  position  in  the  early  stages 
by  dental  splints. 

The  case  cleaned  up  rapidly,  as  such  cases  of  large  losses  usually  do. 

The  method  of  repair  designed  was  by  double  epithelial  flaps,  and  as  a  preliminary 
the  defined  area  outlined  for  the  flap,  which  was  going  to  be  turned  skin  surface  inwards, 
was  subjected  to  X-rays  for  epilation.  The  effect  of  this  was  not  entirely  satisfactory  as 
regards  the  killing  of  the  hair  follicles,  even  though  it  was  pushed  to  the  extent  of  causing 
a  small  burn. 

The  first  operation  was  performed  on  the  line  designed,  and  the  skin  below  and  lateral 
to  the  gap  was  raised  in  two  flaps  and  turned  skin  surface  inwards,  and  there  sutured  to  the 
existing  mucous  membrane.  Along  the  top  of  this  new  skin-lining  the  remaining  mucous 
membrane  was  stretched  and  found  to  be  adequate  to  complete  the  vermilion  border.  The 
raw  area  caused  by  this  transposition  of  skin  was  accurately  measured  with  a  template  and 
a  flap  of  skin  from  the  right  aspect  of  the  neck  and  chest  swung  upwards  to  fill  the  gap. 
The  area  from  which  this  flap  was  taken  was  partly  closed  by  approximation  and  partly 
left  open  to  heal  by  granulation. 

The  result  was  satisfactory. 

This  operation  was  performed  over  a  prosthesis  representing  the  missing  portion  of 
the  mandible,  supported  laterally  on  the  two  fragments.  It  was  found,  however,  that  in 
the  after-treatment  the  pressure  of  the  flaps  on  the  apparatus  was  too  great,  and  the  latter 
was  removed  to  avoid  gangrene.  It  was  found  later  that  the  new  chin  and  lip  were  so  soft 
that  they  could  easily  be  pushed  out  into  any  position.  The  result  of  this  stage  is  shown 
in  fig.  292. 

In  addition  to  the  lack  of  depth  of  the  new  lip,  there  was  marked  absence  of  movement 
in  this  newly  made  portion.  To  improve  both  of  these  defects,  it  was  decided  to  swing 
down  a  nasolabial  flap  on  the  right  side  and  to  interpose  it  between  the  upper  border  of  the 
neck-flap  and  the  vermilion  border.  The  vermilion  border  and  the  inturned  skin-flaps  were 
freely  undercut,  so  that  they  could  be  lengthened  to  cover  over  satisfactorily  the  inner 
surface  of  the  nasolabial  flap. 

The  result  was  gratifying,  both  as  regards  appearance  and  movement  of  the  lip,  the 
latter  being  quite  remarkable. 

It  remains  to  insert  a  bone-graft  of  the  necessary  length,  which  should  present  no 
difficulty. 

The  method  adopted  in  this  case  is  better  than  that  in  the  one  which  follows. 

The  fragments  of  the  mandible  were  maintained  in  better  position,  in  the  first  place 
by  splints,  and  in  the  second  by  the  turning-in  of  an  adequate  epithelial  lining,  while  in 
the  next  case  the  mandibular  arch  was  contracted — mainly  due  to  advancing  the  existing 
mucous  membrane  across  the  gap. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


159 


Fio.  288. — Early  condition. 


Fio.  289.— Healed  condition  (full  face). 


I , YlJX r^x 

i    *&~~^  /     v      ^ 


FIG.  290. — Healed  condition  (profile). 


FIG.  291. — Showing  inturned  flaps  for  lining  and 
ascending  neck  flap  for  covering  of  new  lower  lip. 


100 


PLASTIC    SFRGKRY 


FlO.  292.-- After  first  plastic  :  no  muscular 
control  of  lip. 


FIG.  293. — Nasolabial  cutaneo-muscular  flap 
brought  down. 


FIG.  291. — Present  condition. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


161 


CASE  160 

This  case  did  not  require  any  special  flap  to  complete  repair  after  excision  of  the  scar. 
There  was  a  considerable  soft-tissue  gap  to  fill,  and  the  point  of  the  chin  was  pulled  to  the 
right  by  the  suture. 

The  early  condition  of  this  patient  was  not  recorded  by  photograph,  but  in  the  wound 
on  the  right  side  the  body  of  the  mandible  was  exposed  for  fully  one  inch  and  a  half,  as  a 
wide  devitalised  piece  of  bone.  It  was,  however,  firmly  attached  to  the  posterior  fragment, 
and,  as  a  means  of  maintaining  the  position  of  this  fragment,  I  retained  it  and  passed  a  silver 
wire  from  the  extremity  of  this  dead  end  to  the  anterior  fragment. 

In  the  course  of  time  this  fragment  was  exfoliated  and  the  wire  taken  out. 

At  the  plastic,  performed  on  19.3.17,  a  gap  in  the  bone  still  persisted,  which  was  treated 
by  an  osteo-periosteal  inlay,  by  the  following  method  : 

The  loss  of  bone  was  more  of  the  lower  than  of  the  alveolar  border,  and  after  freshening 
the  ends  it  was  found  possible  to  put  a  retaining  wire  through  the  alveolar  portions.  In 
elevating  the  mucous  membrane  from  the  bone,  however,  a  perforation  in  the  buccal  cavity 
occurred,  which  was  closed  as  far  as  possible  by  catgut  sutures.  Across  the  main  portion 
of  the  gap  an  osteo-periosteal  graft  was  laid  in  two  portions  :  one  on  the  internal  and  another 
on  the  external  aspect. 

Some  mild  suppuration  occurred  after  this  operation,  with  a  few  drops  of  pus  per  day, 
which  persisted  until  a  few  small  splinters  of  the  grafted  bone  came  away  and  the  wire 
was  removed.  Bony  union  was  obtained  by  allowing  the  posterior  fragment  to  swing 
forward  a  little,  and  the  graft  probably  only  acted  as  a  means  of  carrying  bone-forming 
cells  from  one  fragment  to  the  other.  There  was  still  a  depression  of  the  scar  after  bony 
union  had  been  obtained,  and  the  cicatrix  was  removed  and  a  free  fat  graft,  from  the  ab- 
dominal wall,  inserted,  to  reproduce  the  contour.  This  was  done  on  7.9.17,  and  the 
effect  is  well  seen  in  the  photograph,  which  was  taken  two  months  after  the  operation. 

The  scar  in  the  neck  is  one  made  for  ligature  of  the  external  carotid  artery. 


FIG.  295. — Healed  condition. 


FIG.  296. — Intermediate  stage. 


FIG.  297. — Final. 


11 


PLASTIC    SURGERY 

CASE  79 

This  is  a  type  of  case  which  is  intermediate  between  the  preceding  group  and  the  two 
cases  that  are  next  described,  and  is  characterised  by  a  very  large  loss  of  chin  and  lower 
lip,  together  with  the  underlying  bone.  But  the  way  in  which  this  case  differs  from  the 
more  extensive  loss  is  that  a  considerable  amount  of  the  vermilion  border  has  been  preserved 
as  well  as  the  lateral  portion  of  the  chin. 

Fig.  299  shows  the  case  after  it  healed,  and  with  an  appliance  over  which  the  plastic 
operation  was  performed.  The  principle  of  this  operation  was  that  the  existing  vermilion 
border  was  utilised  to  form  the  new  lip  margin  ;  and  mucous  flaps  were  drawn  from  inside 
the  mouth  across  the  back  of  the  new  lip. 

To  make  good  the  loss  of  the  chin,  a  large  descending  flap,  from  the  left  nasolabial  area, 
was  swung  down  and  sutured  to  the  surrounding  parts,  over  the  prosthesis.  The  end  of 
this  flap  was  lost  through  want  of  blood-supply,  and  the  reason  of  its  loss  was  twofold. 
In  the  first  place,  there  was  rather  a  sharp  edge  to  the  appliance,  and  in  suturing  this  long 
flap  a  double  retention  suture,  with  buttons,  from  the  flap  to  the  sound  tissues  on  the  right 
was  utilised.  This  suture  pressed  the  flap  too  firmly  to  the  edge  of  the  prosthesis,  and  by 
the  time  the  blueness  of  the  flap  was  observed,  it  was  too  late  to  save  it.  The  other  reason 
probably  was  that  it  had  no  skin  lining  on  its  oral  surface.  The  result  after  this  accident 
had  occurred  and  the  parts  had  all  healed  up,  is  shown  in  the  next  diagram,  and  a  second 
plastic  operation  was  done  two  and  a  half  months  later. 

The  flaps  are  indicated  in  the  diagram,  and  the  final  plastic  result  is  shown,  photographs 
taken  a  year  later. 

During  this  interval  a  long  rib-graft  had  been  attempted  from  one  fragment  to  the 
other.  The  operation  wound  of  the  bone-graft  healed  by  first  intention,  and  no  discharge 
occurred  subsequently.  However,  owing  to  probably  insufficient  apposition  between  the 
bone-graft  and  the  mandible,  bony  union  did  not  occur,  and  some  absorption  of  the  graft 
took  place. 

A  moderately  satisfactory  dental  appliance,  in  the  form  of  a  denture,  was  however 
fitted,  and  semi-solid  diet  could  be  managed  with  the  aid  of  this  appliance. 

Notes  of  case  are  given  below  : — 

Private  C.  L ,  wounded,  France,  June  30th,  1916,  admitted  2.7.16.  G.S.W.  2, 

1  severe,  4  lower  jaw. 

2.12.16.  Operation  (Captain  Gillies). — For  the  formation  of  the  lower  lip  and  chin. 
Owing  to  lateral  scarring,  the  only  flap  from  the  face  available  was  one  taken  from 

the  left  side  of  the  nose  and  extending  in  a  curve  towards  the  lower  part  of  the  left  ear  where 
its  base  was  situated.  The  mucous  membrane  and  skin  which  had  become  attached  to  the 
jaw  on  the  right  side  were  cut  through  their  whole  thickness  and  swung  forward  to  form 
the  right  portion  of  the  lip  ;  a  relaxation  suture  was  inserted  between  the  two,  as  very 
considerable  tension  was  observed  on  the  left  skin-flap.  The  whole  operation  was  done 
over  an  artificial  denture  and  chin.  Result :  a  considerable  portion  of  the  end  of  the  left 
flap  sloughed,  and  a  triangular  space  on  the  left  cheek  was  left  uncovered,  as  well  as  the 
lower  portion  of  the  wound. 

Operation. — February  28th,  1917,  to  close  circular  opening  below  lower  lip,  left  from 
sloughing  of  flap  after  last  operation.  The  opening  was  surrounded  with  scar  tissue,  which 
was  removed  (as  in  fig.  303). 

13.6.17.  Operation  (Captain  Gillies). — Incision  below  mandible.     Exposure  of  ends 
of  fracture. 

Graft  was  taken  from  the  right  seventh  rib.  A  hole  was  drilled  in  the  right  fragment  and 
a  peg  of  bone  on  left  fragment  was  shaped  to  carry  the  graft.  The  splint  was  very  stiff, 
and  it  was  found  very  difficult  to  immobilise  the  fragments.  This  mobility  resulted,  un- 
fortunately, in  breaking  off  the  peg  on  the  posterior  fragment,  and  the  graft  was  not  therefore 
fixed  into  the  bone  on  the  left  side. 

6.1.18. — Upper  denture  fixed.  There  is  some  movement  between  two  fragments  of 
jaw.  X-ray  shows  the  graft  apparently  united  at  one  end. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


163 


Fio.  298. — Early  condition. 


FIG.  299. — Healed  condition. 


FIG.  300.— First  plastic  :  Outlining  of  flaps. 


FIG.  301.— First  plastic  :    Suture. 


164 


PLASTIC   SURGERY 


Fid.  302. — Result  of  first  plastic. 


FIG.  303. — Second  plastic  :    Excision  of  scar. 


FlO.  304.— Second  plastic  :  Suture. 


Fid.  305.— After  final  plastic. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


165 


Injuries  of  the  soft  tissues  of  the  chin  below  the  lower  lip  do  not  visually 
require  more  than  excision  of  the  scar  tissue,  in  the  usual  manner. 
The  following  two  cases,  however,  have  special  interest : 


CASE  32 

This  case  has  a  photographic  record  of  his  early  condition,  but  not  one  when  it  was 
healed.  The  mandible  united  after  the  comminuted  fracture — present  about  ten  weeks  after 
the  injury — and  the  external  wound  healed  with  a  large  depressed  scar,  adherent  to  the 
bone.  He  was  wounded  on  1.7.16,  and  the  first  plastic  operation  was  performed  three 
months  later.  After  excision  of  the  scar,  a  celluloid  plate  was  inserted  to  raise  the  scar  and 
to  give  the  necessary  contour,  the  plate  being  held  in  position  by  catgut  sutures  to  the 
periosteum  of  the  mandible.  This  operation  was  followed  by  continued  small  haemorrhages, 
and  the  celluloid  plate  was  removed.  Two  months  later  the  scar  was  re-excised,  and  a 
free  fat-graft  from  the  buttock  was  inserted.  The  result  of  this  fat-graft  was  very  successful, 
and  gave  an  excellent  contour.  Whether  any  absorption  has  since  occurred  is  not  deter- 
minable,  as  the  patient  was  discharged  to  duty  a  month  after  the  graft. 


Fio.  306. — Early  condition. 


FIG.  307. — -Final  :    Contour  restored  by  free  fat-graft. 


1GG 


PLASTIC   SURGERY 


CASE  129 

Tliis  case  had  large  central  loss  of  the  soft  tissues  of  the  chin,  which  healed  vip,  with 
a  puckered,  depressed  scar.  There  was  some  ectropion  of  the  lower  lip,  due  to  the  pull  of 
the  scar. 

The  healed  condition,  prior  to  operation,  is  shown  in  fig.  309.  It  will  be  noted  that 
there  are  considerable  radiations  of  the  scar  extending  upwards  and  downwards  from  the 
main  body  of  the  scar. 

However,  excision  was  practised,  and  the  resultant  gap  which  presented  itself  for 
repair  closely  resembled  that  seen  in  fig.  308,  which  is  that  of  the  early  effect  of  the  wound. 

A  difficulty  thus  presented  itself  somewhat  unexpectedly,  as  the  direct  approximation 
of  the  two  skin-edges  was  found  to  evert  the  lip  considerably.  A  decision  had  to  be  made 
between  the  interposition  of  a  flap  between  the  two  skin-edges  or  undercutting  very  freely 
a  lower  flap  and  suturing  it  to  the  chin  with  deep  catgut.  The  latter  procedure  was  the  one 
adopted,  but  although  this  was  markedly  improved  there  was  some  eversion  of  the  lip 
remaining,  in  addition  to  a  smaller  scar  than  hitherto. 

In  reviewing  this  case,  there  is  no  doubt  that  it  would  have  been  better  to  have  employed 
a  flap.  There  is  always  considerable  difficulty  in  undercutting  the  tissues  of  the  chin,  and 
the  greatest  benefit  is  to  be  obtained  in  this  region  by  carefully  sewing  up  the  lower  flap  by 
catgut  to  the  periosteum  overlying  the  mandible. 

The  reason  for  showing  this  case,  which  is  an  indifferent  result,  is  to  bring  forward  the 
difficulties  one  experiences  in  this  particular  region. 


Flo.  308.— Early  condition. 


FIG.  309. — Healed  condition.     (Stain  due  to 
iodine.) 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


167 


FIG.  310. — Excision  of  scar. 


FIG.  311.— Suture. 


mm 

FIG.  312. — Indifferent  result  (see  text). 


168 


PLASTIC   SURGERY 


CASE  139 

This  is  published,  although  an  unfinished  case.  It  is  shown  as  an  attempt  at  restoration 
in  that  not  uncommon  class  of  gunshot  wound  of  the  jaw  in  which  the  whole  body  of  the 
mandible  and  the  soft  overlying  tissues  have  been  blown  away  en  masse.  The  photograph 
of  this  patient,  taken  soon  after  admission,  sufficiently  explains  the  extent  of  the  lesion. 
It  is  an  interesting  point  to  note  that  this  gallant  fellow  walked  several  miles  to  the  dressing 
station  on  July  4th,  1916,  during  the  battle  of  the  Somme,  and  this  very  feat  of  endurance, 
maintaining,  as  it  did,  the  upright  position,  may  have  prevented  an  emergency  tracheotomy 
or  even  a  worse  fate.  The  loss  of  the  lower  lip  and  tissues  of  the  chin  is  complete,  while 
the  amount  of  mandible  remaining  is  represented  by  the  thinned  and  atrophied  ascending 
ramus  of  the  right  side,  and  by  the  ascending  ramus,  angle,  and  one  molar  tooth  on  the  left. 
The  condition  in  January  1917,  after  the  healing  process  was  complete  and  the  general 
condition  more  satisfactory,  is  shown  in  fig.  314. 


FIG.  313. — Early  condition. 


Fio.  314. — Healed  condition. 


At  this  stage  the  first  operation,  which  took  place  on  February  27th,  1917,  was  performed 
under  chloroform-oxygen  anaesthesia  in  the  sitting-position,  administered  by  Lieutenant 
R.  Wade,  R.A.M.C.,  at  the  Cambridge  Hospital,  Aldershot.  The  main  features  of  the 
operation  were  the  freeing  of  the  tongue  and  the  making  of  the  flap  which  formed  the  basis 
of  a  new  lip.  The  result,  as  far  as  it  went,  was  satisfactory,  as  shown  in  fig.  318,  but  the 
absence  of  the  mental  prominence  as  well  as  the  loss  of  function,  were  left  to  be  dealt  with 
until  a  later  stage. 

A  serious  attempt  to  bulge  out  the  new  "  lip  "  by  traction  from  a  head-piece  was  made 
in  conjunction  with  Captain  W.  Kelsey  Fry,  M.C.,  at  the  time  of  this  operation,  but  it  was 
badly  tolerated  and  the  result  was  not  gratifying.  In  view  of  the  general  shortage  of  tissue, 
plastic  flaps  from  the  neck  or  cheek  were  not  indicated,  and  in  view  of  the  success  of  the 
double-pedicled  imbedded  flaps  and  of  the  experience  one  has  had  of  single-pedicled  bridge- 
flaps,  it  occurred  to  me  that  the  employment  of  a  double-pedicled  bridge-flap  from  the  scalp 
would  meet  the  case  without  fear  of  the  blood-supply.  By  a  bridge-flap  is  meant  one  in 
which  the  pedicle  lies  over  healthy  skin,  is  divided  from  the  grafted  terminal  portion  after 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


about  ten  days,  and  is  then  replaced  into  its  original  position.  The  double-bridge  flap, 
though  I  believe  original,  is  merely  the  logical  development  of  double-pedicle  imbedded 
and  single  pedicle  bridge-flaps,  and  it  combined  the  advantages  of  a  double  blood-supply 
and  of  the  provision  of  a  flap  well  distant  from  the  lesion. 

In  this  particular  operation,  which  took  place  on  September  20th,  1917,  at  the  Queen's 
Hospital,  Sidcup,  Captain  J.  L.  Aymard  and  Lieutenant  G.  C.  Birt  assisting,  in  which  ether- 
oil  was  given  by  the  rectal  method  (Lieutenant  R.  Wade),  the  flap  stretched  from  ear  to  ear 
across  the  vertex  and  was  about  3  inches  in  width.  See  fig.  320.  Before  bringing  this  into 


Fio.  315. — Showing  amount  of  mandible  lost. 


FIG.  317. — Stages  in  first  plastic. 


Fio.  316. — First  plastic  :    Freeing  of  tongue  and  advancement  of 
flap  as  beginning  of  new  lower  lip. 


170 


PLASTIC   SURGERY 


position,  the  skin  below  the  buccal  opening  was  raised  by  incision  and  dissection,  and  laid 
on  the  upper  surface  of  a  large  osteo-chondral  graft  from  the  seventh  rib.  This  measured 
some  6  inches  along  its  long  convex  border,  and  was  the  shape  of  a  boomerang  ;  it  included 
about  1  inch  of  the  bony  portion  of  the  rib  and  was  fixed  by  iron  wire  into  the  remains  of 
the  jaw,  bone  to  bone  on  the  left  side  and  cartilage  to  bone  on  the  right,  being  fixed  so  that 
the  point  of  maximum  convexity  of  the  cartilage  became  the  prominence  of  the  chin.  The 
large  scalp-flap  was  then  swung  over  the  face  into  position  so  that  it  covered  the  upper, 
lower,  and  lateral  aspects  of  the  new  "  jaw,"  and  sutured  to  the  surrounding  skin  edges. 


FIG.  318.— After  Brat  plastic. 


FIG.  319. — Second  plastic  :    Scalp  flap  on  double 
pedicle  swung  down  over  bone  graft. 


The  pedicles  were  cut  on  the  eleventh  day  and  returned  to  the  scalp  (fig.  321) ;  the  new  blood- 
supply  of  the  grafted  portion  being  satisfactory,  there  was  no  question  of  gangrene. 

Many  causes  operated  against  asepsis,  of  which  the  more  obvious  were  :  (1)  the  length 
of  operation  ;  (2)  the  difficulty  of  sealing  off  the  junction  of  the  pedicle  and  the  imbedded 
portion  ;  and  (3)  the  very  strong  growth  of  hair  on  the  flap.  Discharge  appeared  at  the 
lower  border  of  the  flap  on  the  fifth  day,  and  has  continued. 

One  must  own  that,  in  planning  this  operation,  it  was  not  expected  that  a  good  functional 
result  would  accrue,  but  some  degree  of  mastication  is  possible  where  there  was  none,  and 
the  gain  to  the  patient  of  having  a  chin  and  a  full  beard  is  almost  certainly  permanent.  The 
secondary  disability  is  a  bare  area  on  the  top  of  the  scalp,  which  is  being  epithelialised. 

In  criticising  this  procedure  the  author  feels  it  would  be  better  either  to  insert  a  piece 
of  metal  or  celluloid  at  the  time  the  scalp-flap  is  brought  down,  to  be  replaced  later  by  an 
osteo-chondral  graft  under  more  aseptic  conditions,  or  else  to  imbed  the  graft  in  two  halves 
in  the  scalp  some  six  weeks  before  it  is  swung  down.  In  this  event,  the  graft,  at  a  later 
stage,  could  be  joined  in  the  middle  and  to  the  remains  of  the  jaw. 

The  cartilage  graft,  with  its  small  attached  portion  of  bone,  continued  to  undergo 
absorption  from  suppuration,  until  it  had  all  absorbed.  The  wires  and  the  sequestrum 
were  removed  in  February  1919. 

The  appearance  now  was  very  much  inferior  to  that  when  the  graft  was  giving  shape 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


171 


to  the  chin,  and  the  portion  of  scalp  which  had  been  grafted  there  had  undergone  a  con- 
siderable amount  of  wrinkling.  The  patient  refused  to  grow  a  beard,  which  might  have 
camouflaged  the  defect,  and  unfortunately  depilatory  doses  of  X-rays  were  applied.  This 
led  to  a  partial  depilation  only,  and  the  resulting  appearance — of  islets  of  hair  surrounded 
by  white,  lifeless-looking  skin — was  a  further  disappointment.  Since  then  two  attempts 
to  remedy  the  man's  condition  have  been  made  without  any  success  ;  and  a  third  attempt 
is  in  progress.  But  the  general  condition,  lowered  by  the  results  of  the  injurv  and  long 
period  under  hospital  treatment,  is  such  that  the  prospect  is  not  very  hopeful. 


FlQ.  320. — Second  plastic  :    lateral  view. 
(Note  pedicle.) 


FIG.  321. — Pedicles  severed  and  returned. 


172  PLASTIC   SURGERY 

CASE  76 

This  case  was  received  in  my  clinic  only  three  months  after  being  wounded. 

This  patient,  though  not  giving  such  a  ghastly  appearance  in  the  early  photograph 
as  the  previous  one,  suffered  a  greater  loss  both  of  the  bone  and  of  the  soft  tissues.  The 
whole  of  the  upper  lip  and  the  whole  chin  had  been  swept  away,  and  the  tongue  was  adherent 
to  the  margin  of  the  wound.  The  loss  of  bone  in  the  mandible  is  very  extensive,  being, 
however,  just  in  front  of  the  angle. 

Three  months  after  wound  the  first  plastic  was  done.  The  dental  officer  in  charge  of 
the  case  was  Captain  Hornyblower,  working  under  Captain  L.  A.  B.  King,  R.A.M.C.  A 
large  vulcanite  artificial  chin  was  made  and  attached  by  a  splint  to  the  upper  teeth,  and 
an  attempt  was  made  to  make  the  new  mouth  over  this. 

The  result  was  indifferent,  and  no  attempt  to  remake  the  chin  was  carried  out. 

Had  it  been  possible  to  have  retained  the  appliance,  a  satisfactory  mouth  might  have 
eventually  been  obtained,  but  the  swinging  in  of  the  flap  on  the  left  side  had  pulled  over 
the  corner  of  the  mouth  to  a  very  considerable  extent.  When  all  had  healed  up  there  was 
considerable  tension  of  the  new  lip,  and,  after  consultation  with  the  dental  surgeon,  it  was 
decided  to  remove  the  prosthesis.  When  this  was  done,  it  was  thought  necessary  to  close 
the  lower  opening  in  order  to  prevent  the  dribbling. 

The  intermediate  stage  photographic  records  are  missing.  It  consisted  of  the  widening 
of  the  mouth  to  the  left,  so  that  access  to  the  buccal  cavity  could  be  obtained  by  the  dental 
surgeon,  Captain  W.  Kelsey  Fry,  M.C.,  R.A.M.C.,  working  in  conjunction  with  Sir  Francis 
Farmer,  who  designed  an  appliance,  next  attempted  to  stretch  forward  the  tissues  of  the 
chin,  which  had  now  become  softer  and  more  amenable  to  traction.  The  patient,  however, 
was  not  particularly  tolerant  to  this  procedure,  and  I  felt  that  perhaps  one  was  wasting 
time,  and,  after  consultation  with  Sir  Francis  Farmer  and  Captain  Fry,  who  advised  one  to 
carrv  out  a  more  radical  procedure  for  the  building  up  of  a  new  chin,  the  author  obtained 
from  Lieutenant  W.  W.  Edwards,  the  sculptor,  a  kind  of  chin  in  plaster,  the  size  of  a  pros- 
thesis necessary  to  make  a  chin  over  it.  This  was  later  cast  in  aluminium,  and  attached 
by  suture  to  the  upper  teeth,  on  which  was  a  cap-splint.  Around  this  artificial  apparatus 
was  built  an  epithelial  pouch,  in  the  following  manner.  Three  skin-flaps — two  being  lateral 
and  one  central  from  below — were  reflected  and  sutured,  with  continuous  catgut,  over  the 
middle  raw  surface  outwards.  These  flaps  were  accurately  designed  beforehand  in  tinfoil. 

The  raw  area  thus  created  by  the  turning  in  of  these  skin-flaps,  which  included  the 
prominence  of  the  new  chin,  was  also  accurately  gauged  beforehand,  and  a  model  cut  in 
rolled-out  lead  plate,  to  which  were  added  the  necessary  pedicles,  to  carry  a  large  double 
pedicle  scalp-flap  down  to  the  chin.  The  appearance  of  this  flap  is  shown. 

It  all  healed  by  first  intention,  the  pedicles  being  carefully  attached — sewn  skin-edge 
to  skin-edge. 

The  central  portion  of  the  scalp  was  skin-grafted,  the  Thiersch  grafts  being  taken  from 
a  tattoo  mark  in  his  right  forearm,  the  idea  being  that  the  blue  tattoo  mark  would  show 
less  conspicuously  than  white  skin.  It  is  interesting  to  note  that  this  mark  contained  the 
letters  "  Bert,"  and  up  to  the  time  of  writing,  which  is  six  months  after  the  operation, 
the  letters  are  still  quite  clearly  legible  on  the  top  of  this  patient's  scalp.  The  pedicles 
were  returned  under  local  anaesthesia  without  difficulty,  one  of  them  being  done  for  me  by 
Captain  Waugh,  U.S.,  M.R.C.,  and  in  the  main  operation  I  had  the  assistance  of  Major 
Dorrance,  U.S.,  M.R.C.  The  effect  of  this  operation  is  to  have  produced  an  epithelial  pouch 
on  the  front  of  the  man's  neck.  The  back  wall  of  this  pouch  is  lined  by  the  previously 
existing  lower  margin  of  his  mouth,  which  was  not  destroyed.  It  is  intended  to  divide  this 
inner  partition,  to  spread  it  along  the  margin  of  the  new  lip  as  a  red  margin.  This  will  have 
the  effect  of  making  the  two  cavities  into  one,  and  Sir  Francis  Farmer  has  taken  a  cast 
which  indicates  these  two  cavities  as  they  exist  at  present.  It  is  intended  to  fit  a  combined 
chin  and  lower  denture  to  the  remains  of  the  mandible.  No  crinkling  or  retraction  of  the 
grafted  scalp-flap  is  occurring  now — three  months  after  the  operation — and  a  satisfactory 
beard  could  be  easily  grown.  The  patient,  however,  prefers  to  shave. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


173 


FIG.  322. — Healed  condition  :  Front. 


FIG.  323. — Healed  condition  :  Profile. 


FIG.  324.— After  first  plastic. 


FIG.  325. — Scalp  flap  on  double  pedicle  brought  down 
over  inturned  skin  flaps  from  cheeks  and  neck. 


174 


PLASTIC   SURGERY 


Fio.  326. 


FIG.  327. 


FIG.  328. 
After  return  of  pedicles  :  Front  and  side  views.     Prosthetic  chin  in  position. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN  175 

Remarkable  further  progress  has  been  made  in  this  case  in  that  into  such  a  plastic  chin 
containing  no  musculature  a  new  mandible  has  been  successfully  grafted.  Also  see  opera- 
tion notes.  X-ray  of  the  bone-graft  is  too  late  for  insertion. 

An  excellent  functional  result  has  been  obtained. 

OPERATION  NOTES 

Gunner  W ,  wounded  France,  16.9.16,  admitted  30.9.16.  G.S.W.  2,  4,  8,  1,  9,  1. 

Fracture  through  both  horizontal  rami  just  in  front  of  angles,  whole  of  intervening  jaw 
missing.  On  right  side  there  are  stumps  remaining  of  M.  2.  Left  side  M.  2  is  involved. 

4.12.16.  Plastic  operation  (Captain  Gillies). — The  main  feature  of  this  operation  in 
the  attempt  to  form  the  mouth  was  that  a  local  flap  cut  from  the  right  cheek  with  its  base 
upwards,  was  swung  down  and  placed  over  a  large  prosthesis  and  made  to  meet  the  whole 
thickness  of  lip  which  remained  at  the  left  angle  of  the  mouth.  This  was  cut  in  a  circular 
fashion  about  half  an  inch  from  its  mucous  border  to  enable  it  to  swing  forwards.  No 
attempt  was  made  to  close  over  the  large  gap  below.  No  relaxation  sutures  were  used  other 
than  catgut  and  deep  silkworm  in  the  flap  itself. 

8.3.17.  Operation  (Captain  Gillies). — A  flap  dissected  up  from  left  upper  lip  of  cloaca 
with  its  base  at  level  of  angle  of  mouth,  inner  edge  being  about  1  inch  distant.  Mucous 
membrane  along  floor  of  mouth  united  to  that  lining  edge  of  cloaca  or  region  of  flap.  The 
under  surface  of  tongue  was  freed  from  the  adhesions  binding  it  down  to  floor  of  mouth. 
Two  strong  silk-worm  gut  ligatures  passed  through  substance  of  tongue  and  tied  over  metal 
bar  of  bridge  fixed  on  upper  teeth,  thus  lifting  the  organ  and  preventing  formation  of  further 
adhesions.  Skin  freed  along  remaining  upper  lip  of  cloaca,  freshened  inner  part  of  lip 
twisted  upon  itself  and  sutured  to  base  of  tongue.  Lower  lip  of  cloaca  freshened.  A  flap 
raised  by  taking  incision  from  the  outer  third  of  lip  downwards  and  outwards  to  the  right 
neck  at  about  the  level  of  angle  of  mandible.  Remaining  portion  of  cloaca  edge  on  left 
side  freshened  and  undercut,  deep  catgut  retention  sutures  being  used  for  anchoring  the 
large  flap  into  its  new  position.  Skin  surfaces  united  with  horsehair,  thus  entirely  closing 
cloaca.  A  vulcanite  splint  was  fixed  in  position  along  floor  of  the  mouth  by  means  of  sutures, 
in  order  to  supply  contour  over  the  chin  region. 

21.6.17. — Small  plastic  operation  on  lip  to  enlarge  mouth. 

7.10.17. — Transfer  to  Park  Hospital,  Hither  Green.     Scarlet  Fever. 

14.12. 17.— Readmitted. 

11.5.18.   Operation  (Major  Gillies)  for  new  chin  and  lower  lip. 

Method. — Model  of  inside  measurements  of  new  chin  made  in  cast  silver  and  laid 
over  existing  aperture  (designed  with  the  assistance  of  Lieutenant  J.  Edwards)  and  suspended 
from  the  upper  teeth.  Over  this  chin-piece  three  skin-flaps  (two  lateral  and  one  inferior) 
were  sewn  over  their  skin  surfaces  towards  the  prosthesis  which  now  lay  in  a  complete 
epithelial  pouch.  Sutured  by  catgut,  with  assistance  of  Captain  H.  C.  Malleson,  R.A.M.C., 
and  Major  Dorrance,  M.R.C.,  U.S.A.  The  raw  surfaces  from  which  these  flaps  were  taken, 
as  well  as  that  which  lay  over  the  chin,  were  covered  in  by  a  double-pedicle  scalp-flap,  which 
was  swung  over  the  face  into  position.  In  cutting  the  pedicles  of  this  flap  care  was  taken  to 
cut  and  ligature  both  the  anterior  and  posterior  branches  of  the  temporal  artery,  so  that  the 
main  force  of  this  blood-vessel  should  be  directed  into  the  pedicle.  Both  the  inturned  flap  and 
the  scalp-flap  were  accurately  cut  to  previously  designed  models  and  all  fitted  accurately. 

Skin  graft  thigh  to  scalp,  partial,  and  also  tattoo-mark  in  arm  transferred  to  same  area. 

Later.  An  osteo-periosteal  graft  from  the  tibia,  seven  inches  in  length,  was  wired 
to  the  mandibular  remains  in  September  1919.  Healing  was  by  first  intention.  The  appear- 
ance has  not  been  altered. 

Bony  union  has  occurred  at  both  ends,  and  a  functional  dental  appliance  fitted  over 
the  new  mandible,  giving  from  50  to  60  per  cent,  of  normal  mastication. 

Figs.  329 — 332  illustrate  a  modification  of  the  method  of  forming  a  chin  used  in 
Case  76.  It  has  been  employed  in  two  cases,  both  of  which  are  as  yet  unfinished  but 
give  every  promise  of  an  excellent  result. 


176 


PLASTIC   SURGERY 


Fio.  329. — Flaps  for  lining  of  new  chin  outlined. 


Fia.  330. — Lining  flaps  being  inturned  over  a 
prosthetic  chin.     Forehead  flap  outlined. 


Fio.  331. — Covering  flap  for  chin  being  swung 
down  from  forehead. 


Fio.  332.— Suture.     Pedicles  tubed. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN  177 


BONE-GRAFTING    TO    THE    MANDIBLE 

The  reconstruction  by  bone  of  the  missing  portions  of  the  mandible  is  the 
ultimate  aim  in  the  great  majority  of  severe  injuries  of  the  lower  lip  and  mandible. 
In  quite  a  number  of  cases  there  is  a  much  larger  loss  of  bone  than  of  the  soft 
tissues.  These  present  no  difficulties,  and  the  operation  for  bone-grafting  is 
uncomplicated. 

It  is  not  proposed,  in  this  volume,  to  enter  at  all  fully  into  either  the  theory 
or  practice  of  this  procedure.  A  rough  outline  of  the  principles  is  indicated 
below,  and  the  various  methods  that  the  author  has  adopted,  or  seen  adopted 
in  his  actual  experience.  The  author  was  very  strongly  opposed  in  the  first 
two  years  of  his  experience  to  the  use  of  any  foreign  body,  such  as  wire  or  plates, 
as  a  method  of  fixation.  In  this  he  was  influenced  by  the  work  of  Albee  and 
Lindemarm.  In  the  early  stages,  the  operation  of  bone-grafting  was  very 
much  on  trial,  and  in  these  early  days  many  cases  were  operated  on  too  soon 
after  the  healing  of  the  wound,  and  frequently  in  tissues  which  were  not  suffi- 
ciently vascular  to  tolerate  the  graft.  The  method  of  auto-fixation  which  was 
adopted  was  exceedingly  difficult,  but  a  large  number  of  cases  of  successful 
rib-grafts  were  obtained  in  1916  and  beginning  of  1917.  The  method  of  auto- 
fixation  was,  broadly,  the  making  of  a  hole  in  one'  fragment  and  a  peg  on  the 
other  fragment  fit  respectively  into  a  hole  and  a  peg  of  a  graft.  When  this 
fixation  was  satisfactory,  the  cases  were  most  successful.  Several  of  these 
grafts  have  been  examined  two  years  after  their  insertion,  and  the  function- 
when  the  dental  condition  allows  it — is  remarkably  good. 

One  officer  who  had  two  inches  of  rib  inserted  (fig.  337)  can  crack  a  brazil- 
nut.  Owing,  however,  to  a  certain  number  of  disappointments  inseparable 
from  this  method — such  as  the  breaking  of  the  peg  or  of  the  fragment  at  the 
last  moment  of  the  operation — a  number  of  these  grafts  failed,  the  graft  being 
absorbed,  either  by  sepsis  or  aseptically. 

Concurrently  with  this  method  the  author  adopted  the  osteo-periosteal 
method  advocated  by  French  surgeons,  but  reserved  it  in  the  first  instance  for 
gaps  of  small  dimensions.  The  method  was  gradually  extended  to  larger  gaps, 
and  in  the  author's  opinion  it  is  specially  suitable  for  grafts  :  (1)  in  newly  made 
soft  tissues  ;  (2)  in  very  large  gaps  round  corners  where  one  fragment  is  prac- 
tically non-existent  while  the  other  is  fixable  by  splints  ;  (3)  where  the  fragments 
can  be  maintained  in  position  by  dental  splints — that  is  to  say,  they  bear  sound 
teeth  which  can  be  utilised  for  intra-oral  fixation  ;  in  this  case  the  gap  may 
be  quite  short,  as  in  a  pseudo-arthrosis,  or  qviite  large,  as  where  the  bone  is 
quite  lost  from  molar  region  to  molar  region,  a  tooth  remaining  on  each  fragment, 

12 


178  PLASTIC   SURGERY 

It  is  also  claimed  by  the  French  that  this  method  can  be  utilised  at  a  much 
earlier  date  than  a  block  graft.  The  author  dissociates  himself  from  this  view 
as  he  thinks  it  is  unsound,  although  not  disputing  the  possibility  that  osteo- 
periosteal  graft  more  readily  forms  bone  in  a  septic  wound  than  do  the  block 
grafts.  In  all  cases,  a  due  interval  should  be  allowed  to  elapse  ;  this  interval 
varies  according  to  the  condition  of  the  tissues  into  which  the  graft  has  to  be 
placed  and  to  the  length  of  time  that  the  case  has  remained  septic  after  the 
wound.  The  author  is  convinced  that  this  method  has  a  definite  place  in  the 
methods  to  be  chosen  for  special  cases. 

Still  adhering  to  the  principle  of  auto-fixation,  the  author  went  to  the 
tibia  for  losses  in  the  region  of  the  angle  of  the  mandible  in  which  it  is  desirable 
to  replace  and  maintain  the  posterior  fragment  as  far  back  as  possible.     In 
order  to  do  this,  specially  shaped  blocks  of  tibia  were  laboriously  fashioned  to 
make  an  accurate  reconstruction  of  the  angle  and  missing  portion  of  the  body 
of  the  bone.     On  the  posterior  end  of  the  graft  was  usually  left  a  peg  of  bone 
which  was  fitted  up  a  canal  made  in  the  medullary  cavity  of  the  posterior  frag- 
ment.    The  anterior  fixation  Avas  made  by  similar  but  smaller  wedging  or  by 
a  bone-peg.      The  X-ray  of  two  such  examples  is  amongst  the  series  shown. 
The  method  is  very  interesting,  and  exceedingly  good  when  successful.     It  is, 
however,  much  too  difficult  to  perform,  and  requires  an  operation  lasting  some- 
times over  three  hours.     The  graft  also  has  to  be  handled  considerably  in  order 
to  make  it  fit  accurately.     Other  disabilities  of  the  method  are  that  accidents 
with  the  graft  are  liable  to  occur  in  taking  it  from  the  tibia,  and  in  several  cases 
the  shaped  graft — after  its  removal  from  the  tibia --was  split  at  some  part. 
Two  good  examples  are  shown  in  figs.  346  and  348.     A  third  is  shown  in  fig.  350  : 
in  this,  however,  the  shaped  graft,  taken  from  a  brittle  tibia,  broke  twice  before 
its  shape  was  complete.     In  fitting  in  the  remains  into  the  recesses  made  for 
it  in  the  fragments,  the  fragments  broke.     As  a  last  resort  the  graft,  now  whittled 
down  to  a  thin  plate  of  compact  bone,  was  wedged  into  the  fragments  at  each 
end  and  retained  there  by  a  silver  wire  passed  from  one  fragment  to  the  other 
without  passing  through  the  graft.     The  result  was  strikingly  good,   a  most 
solid  bony  union  occurred  despite  the  various  disasters  that  had  happened. 

The  pedicle  bone-graft,  as  advocated  by  Cole,  was  adopted  in  a  certain 
number  of  cases,  one  or  two  examples  of  which  are  shown  in  figs.  352  and  354. 
The  operation  is  easy  to  perform,  is  not  liable  to  sepsis,  and  is  a  method  of  choice 
for  certain  types.  It  would,  however,  appear  to  have  no  real  advantage  over 
the  plain  block-graft  from  the  ilium.  Its  disadvantages  would  appear  mainly 
to  be  :  (a)  that  the  union  is  liable  to  be  springy  as  it  occurs  only  along  the  lower 
border  of  the  mandible  and  no  regeneration  of  the  bone-tissues  of  the  alveolar 
portion  occurs ;  (b)  if  used  in  large  gaps  one  is  apt  to  get  insufficient  apposition 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN  179 

of  good  bone  between  the  graft  and  the  mandible  ;  (c)  cosmetic-ally,  it  is  in- 
different ;  (d)  a  query  is  also  raised  as  to  whether  the  taking  of  the  lower  border 
from  the  healthy  part  of  the  mandible  may  not  unduly  weaken  that  portion, 
especially  when  absorption  of  the  alveolar  bone  occurs  after  the  teeth  come  out. 

It  is  a  very  easy  operation  to  perform  for  a  loss  of  bone  occurring  in  the 
middle  of  the  body  of  the  mandible  ;  but  its  advantages  even  in  this  simple 
type  of  case  do  not  outweigh  its  disadvantages,  and  it  would  not  appear  to  give 
better  results  than  the  straight  ilium  block  operation. 

For  large  gaps,  Lieutenant-Colonel  H.  S.  Newland,  D.S.O.,  A. A.M. C.,' had 
advised  the  use  of  combined  pedicle  and  block-graft.  A  small  pedicle  bone- 
graft  is  fixed  to  the  main  graft  in  the  centre  of  the  gap  with  the  idea  that  the 
osteogenetic  process  should  commence  in  the  middle  as  well  as  at  the  end  of 
the  graft.  The  principle  seems  sound,  and  is  an  improvement  on  the  Cole 
pedicle  graft,  in  that  it  regenerates  bone  not  only  along  the  lower  border  but 
also  up  towards  the  alveolus. 

The  next  stage  in  the  hisbory  of  bone-grafting  was  the  use  of  block  tibia 
and  ilium  grafts  of  simple  character,  wired  into  position  between  the  frag- 
ments. The  adoption  of  this  method  by  the  various  surgeons  in  the  Queen's 
Hospital,  Sidcup,  was  generally  due  to  Sir  Arbuthnot  Lane.  It  is  so  simple 
and  successful  that  little  interest  remains  in  the  operation,  and  provided  that 
no  concealed  sepsis  is  lit  up  by  the  operation,  .110  cases  of  failure  to  obtain 
bony  union  are  now  reported. 

The  Author's  Method. — Indications  :  where  the  loss  of  bone  includes  the 
whole  of  the  ascending  ramus,  such  as  occurs  after  excision  of  the  mandible 
for  tumour.  A  piece  of  the  seventh  or  eighth  rib  taken  from  the  opposite 
side,  including  the  costochondral  junction  and  the  point  of  maximum  convexity. 
The  bony  portion  of  the  graft  is  wired  to  the  freshened  anterior  fragment.  The 
maximum  point  of  convexity  forms  a  new  angle  of  the  mandible,  while  the 
ascending  ramus  is  represented  by  that  portion  of  costal  cartilage  which  runs 
upwards  to  the  sternum.  A  false  joint  in  the  neighbourhood  of  the  glenoid 
fossa  is  thus  made,  and  a  cosmetic  and  functional  result  accrues  (figs.  333-335). 
The  author  also  undertook  a  number  of  bone-slides  where  attempts  were 
made  to  interpolate  partially  or  completely  detached  pieces  of  bone  from  the 
end  of  a  fragment  into  the  gap  between  the  two. 

A  few  of  these  were  successful,  but  the  majority  ended  in  non-union,  owing 
to  the  fact  that  insufficient  freshening  of  the  eburnated  ends  of  the  fragments 
had  been  made. 

A  simpler  method  than  this  has  been  adopted  by  Billington.  The  surfaces 
of  the  fragments  are  freshened  and  a  split  rib  laid  over  the  gap  and  the  two 
fragments  with  a  considerable  overlap.  The  soft  tissues  are  merely  sutured 


180  PLASTIC   SURGERY 

over  this  m-aft.     When  all  is  healed,  the  case  is  handed  to  the  dentist,  who 

O 

fixes  the  necessary  splint.  In  all  previous  methods  the  mandibular  fragments 
are  fixed  as  far  as  possible  in  a  correct  position  prior  to  operation.  Billington's 
method  has  the  virtue  of  simplicity,  but  can  have  no  place  as  a  method  of 
controlling  the  edentulous  fragment. 

It  is  practically  agreed  that  the  posterior  fragment,  when  once  it  has  swung 
forward,  which  it  does  in  the  vast  majority  of  cases,  cannot  be  controlled  satis- 
factorily by  any  intra-oral  method.  The  pressure  of  the  apparatus  necessary 
to  do  so,  in  my  experience,  invariably  causes  pain,  discomfort,  and  ulceration 
of  the  mucous  membrane  over  the  ascending  ramus.  In  such  cases  it  is  essential 
to  insert  a  block  of  bone  which  will,  by  its  length,  press  back  the  posterior 
fragments.  Adequate  fixation,  either  by  wire  or  wedging,  must  also  be  provided, 
so  that  the  posterior  fragment  is  maintained  there. 

Summing  up  the  present  position  of  bone-grafting  of  the  mandible, 
therefore  :  (1)  The  main  source  of  bone  should  be  the  ilium.  The  fragments 
of  the  mandible  should  be  maintained  in  their  normal  positions  either  by 
intra-oral  apparatus,  or  by  the  graft.  The  method  of  fixation  of  a  block-graft 
should  be  by  wire.  Some  degree  of  auto-fixation  on  the  edentulous  displaced 
posterior  fragment  is  desirable.  Union  is  more  rapid  when  the  graft  overlaps 
the  fragments  either  on  its  inner  or  its  outer  aspects.  (2)  The  osteo-periosteal 
graft  is  indicated  in  very  large  gaps,  in  very  small  controlled  gaps,  and  in 
tissues  the  blood-supply  to  which  is  poor.  It  is  also  useful  for  bony  losses  in 
the  symphysis  region  where  a  marked  curve  is  required.  (3)  Pedicle  graft 
(Cole),  combined  with  a  superimposed  block-graft  (Newland),  is  an  alternative 
and  a  very  sound  method  of  the  plain  ilium  graft.  (4)  Billington's  late  fixation 
method  no  doubt  has  a  place  in  cases  where  loss  is  minimal  and  where  there 
is  but  slight  and  easily  remediable  deformity  ;  but  the  many  late  results  of 
this  method  seen  by  the  author  do  not  encourage  one  to  adopt  it  as  a  routine. 
(5)  The  autologous  osteochondral  graft  (author)  has  not  a  large  place  in  war 
injuries,  but  is  the  only  method  yet  evolved  to  cope  with  the  condition  resulting 
from  the  removal  of  half  the  mandible  in  civil  practice.  In  one  such  case  its 
adoption  has  resulted  in  a  marked  cosmetic  improvement,  and  also  a  small 
improvement  in  function  due  to  the  provision  of  an  extra  point  d'appui  for  the 
symphysis.  Explanatory  diagrams  are  given. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN 


181 


Fio.  333.— The  defect. 


FIG.  334. — The   opposite   eighth   or  seventh   rib 
the  sourco  of  the  graft. 


Fio.  335. — Graft   in  position. 
THE   AUTHOR'S  OSTEOCHONDRAL  GRAFT. 


182  PLASTIC   SURGERY 


The  skiagrams  which  follow  arc  selected  from  among  a  very  large  number 
of  cases  as  being  fairly  typical  of  the  various  methods  discussed  in  the  preceding 
pages. 

For  the  most  part  they  require  no  description,  the  condition  being  in  each 
case  evident  to  the  practised  eye. 

After  there  is  firm  union  it  can  nearly  always  be  made  possible  to  fit  a 
denture,  by  employing  the  author's  modification  of  the  Esser  Inlay  operation 
to  recreate  the  labiogingival  sulcus,  as  described  in  the  chapter  on  Principles. 
This  was  achieved  even  in  Case  E,  though  here,  as  is  usual  in  such  terrible  cases, 
the  denture  is  a  cosmetic  rather  than  a  functional  triumph — the  paucity  of 
teeth  precluding  any  attempt  to  fit  a  masticatory  appliance. 

No  example  is  shown  of  an  osteochondral  graft,  as  the  major  portion  of 
the  graft,  being  cartilaginous,  throws  no  shadow,  and  the  skiagraphic  appearance 
presents  nothing  peculiar  to  this  method. 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN  183 


Fio.  33G.— Case  A.  (Rib  graft.) 


Fio.  337.— Case  B.  (Bib  graft.) 


FIG.  338.— Front.  FIG.  339._Lateral. 

Case  C.     Osteo -periostea!  graft  from  tibia. 


IM 


PLASTIC   SURGERY 


Fio.  340.— Case  D.  (26.8.18). 


FIG.  341.— Case  D.  (7.11.18). 


FIG.  342.— Case  D.  (7.11.18). 
Osteo-periosteal  graft  from  tibia. 


INJURIES   OF  THE   LOWER  LIP  AND   CHIN 


185 


FIG.  343.— Case  E.  (1.10.18). 


FIG.  344.— Caso  E.  (7.7.19). 


FIG.  345.— Caso  E.  (7.7.19). 
Oeteo-periosteal  graft  from  tibia. 


186 


PLASTIC   SURGERY 


Fid.  340. — Case  F. 
(The  oivli  of  tho  fragments  are  outlined  with   dots.) 


FIG.  347.— Case  F.    (Tibial  Block.) 


Fio.  348.— Case  G.    Tibial  Block.     (12.2.18.) 


FIG.  349.— Case  G.    Tibial  Block,     (10.12.18.) 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN  187 


Fia.  350.— Case  II.     Tibial  Block.     (20.0.18.) 


Fio.  351.— Case  H.     Tibial  Block.     (3.7.19.) 


Fio.  352.— Case  I.  (8.8.18.) 


FIG.  353.— Case  I.     Pedicle  graft.     (15.11.18.) 


188 


PLASTIC   SURGERY 


FIQ.  354.— Case  J.  (14.8.18.) 


FIG.  355.— Case  J.     Pedicle  graft.     (18.12.18.) 


Flo.  356.— Case  K.     Lateral.     (14.1. 18.) 


Fio.  357.— Case  K.     Ilium  Block.     (14.11.18.) 


INJURIES    OF    THE    LOWER    LIP    AND    CHIN  189 


Fio.  358. — Case  L.     Major  Chubb's  case. 


FIG.  359.— Case  L.     Ilium  Block. 


Fio.  360.— Case  M.     Ilium  Block. 


PROSTHESIS  AND   PALATES 


CHAPTER    V 
PROSTHETIC  APPLIANCES  IN  RELATION  TO  PLASTIC  SURGERY 

IN  the  treatment  of  injuries  of  the  face,  with  laceration  or  destruction  of  the 
soft  tissues,  with  or  without  loss  of  the  bone,  it  is  the  aim  of  the  plastic  suigeon 
to  replace  the  tissues  to  their  normal  position  and  so  restore  the  contour  of 
the  face.  When  these  injuries  involve  the  tissues  of  the  oral  cavity  with  con- 
sequent loss  of  teeth,  the  surgeon  has  the  additional  aim,  in  his  treatment,  of 
maintaining  the  mouth  in  such  a  condition  that  the  patient  will  later  be  able 
to  wear  a  functional  denture.  In  the  attainment  of  this  aim  in  the  treatment 
of  many  of  the  cases,  the  surgeon  has  a  valuable  aid  at  his  command  in  the  use 
of  prosthetic  appliances — that  is  to  say,  mechanical  means  of  maintaining  the 
hard  tissues  in  their  correct  alignment.  These  prosthetic  appliances  are  usually 
made  by  a  dental  surgeon  working  in  the  closest. co-operation  with  the  plastic 
surgeon,  and  it  must  be  borne  in  mind  that  the  appliances,  to  fulfil  their  objects 
successfully,  should  be  of  simple  construction,  removable  as  far  as  possible,  easily 
kept  clean  by  the  patient,  and  in  some  cases  of  value  in  mastication  as  well. 

The  appliances  which  may  be  of  service  are  so  numerous  and  varied  that, 
for  the  purposes  of  description,  it  is  necessary  to  classify  according  to  regions 
the  injuries  which  necessitate  their  use. 

1.  Those  involving  the  oral  cavity  ; 

2.  Those  involving  the  nose  ;   and 

3.  Those  involving  the  eyes. 

Injuries  involving  the  oral  cavity  are  frequently  complicated  by  fractures 
of  the  maxilla  or  the  mandible,  with  or  without  loss  of  bone,  but  it  is  not  intended 
here  to  describe  the  treatment  of  such  fractures  except  as  they  affect  the  work 
of  the  plastic  surgeon.  It  is  advisable  that  this  class  be  further  subdivided 
as  follows  : 

(a)  Without  loss  of  bony  tissue,  and 

(6)  With  loss  of  bony  tissue. 

(a)  In  dealing  with  cases  in  which  there  is  no  loss  of  tissue,  the  main  object 
of  the  prosthetic  appliance  is  to  maintain,  in  their  normal  positions,  such  parts  of 
the  hard  or  soft  tissues  as  may  have  been  displaced  by  the  injury,  and  to  prevent 
the  gradual  obliteration  of  the  dental  sulcus  by  adhesions,  the  latter  object 
being  of  the  greatest  impoitance  in  the  future  fitting  of  dentures. 

13  103 


194 


PLASTIC    SURGERY 


fragments  of  hard  tissue  are  brought  into  alignment  and  the 
eonouaincS  by  means  of  a  simple  dental  splint,  sin  .lar  to^  ho™ 
in  fig.  361,  and  when  these  cases  involve  laceration  of  the  soft 


FIG.  361.  —  Simple  dental  splints. 

are  likely  to  obliterate  the  dental  sulcus,  removable  vulcanite  flanges  are  fitted 
to  the  splint,  as  shown  in  fig.  362,  to  prevent  the  soft  tissues  encroaching  upon 
and  destroying  the  sulcus.  When  there  is  only  laceration  of  the  soft  tissues 

a  similar  appliance  or  a  denture  with  exaggerated 
flanges  is  used  for  the  same  purpose. 

There  are  many  variations  of  the  use  of 
flanges  attached  to  splints  or  dentures  ;  the 
upward  support  of  a  lacerated  and  drooping 
upper  lip  may  be  taken  as  a  typical  example. 

A  distinct  type  of  case  sometimes  met  with 
js  that  of  a  marked  deformity  of  the  upper  part 
of  the  face,  but  without  loss  of  bone,  due  either  to  a  complete  horizontal 
fracture  of  the  maxilla  with  a  backward  displacement,  or  to  a  complete 
vi-itical  fracture  with  overlapping  of  the  fragments,  resulting  in  the  falling  in 
of  the  soft  tissues,  which  gives  the  appearance,  on  a  casual  examination,  of  a 
case  with  loss  of  hard  tissue.  To  restore  the  contour  of  the  face,  it  is  necessary 


Flo.  362.  —  Splint  with  flange  to  preserve 

dental  sulcus. 


PROSTHESIS    AND    PALATES 


195 


to  reduce  the  deformity  of  the  hard  parts,  and  for  this  purpose  an  apparatus 
first  used  by  Major  Rishworth,  N.Z.U.C.,  has  proved  of  great  value.  This 
appliance,  as  shown  in  fig.  863,  consists  of  a  headpiece  attached  by  two  vertical 
bars  to  a  splint  on  the  teeth  of  the  mandible,  the  latter  being  fixed  in  the  slightly 
open  position.  A  splint  is  also  fixed  on  the  displaced  fragment  of  the  upper 
jaw,  and  the  necessary  forward  tension  is  produced  by  means  of  screws  attached 
to  the  vertical  bars.  In  some  such  cases  of  overlapping,  it  is  advisable  to  reduce 
the  displacement  surgically,  and  to 
hold  the  fragment  in  good  alignment 
by  means  of  simple  dental  splints. 

When  there  is  only  a  loss  of  the 
soft  tissue  of  the  lips,  etc.,  the  neces- 
sary prosthetic  appliance  consists  of  a 
dental  splint  carrying  a  removal  flange 
moulded  in  such  a  way  that  the  plastic 
surgeon  is  enabled  to  build  the  new 
lip  over  it,  maintain  the  correct  con- 
tour, and  form  a  new  dental  sulcus. 
In  cases  of  extensive  loss  of  the  soft 
parts  of  the  cheek,  it  is  not  only  neces- 
sary to  make  a  flange  over  which  to 
build  the  soft  tissues,  but  the  jaws 
must  be  fixed  in  the  position  of  the 
open  bite,  to  prevent  any  trismus  re- 
sulting from  the  contraction  of  the 
scar  tissue. 

(b)  In  many  instances  there  is  a 
loss  of  hard  tissue  in  addition  to  that 
of  soft  tissue,  such  as  the  loss  of  the 
pre-maxilla.  This  loss  must  be  replaced 

by  a  prosthetic  appliance  as  shown  in  fig.  364,  for  the  purpose  of  maintaining  the 
remaining  bony  tissue  in  its  correct  alignment,  and  to  enable  the  surgeon  to 
restore  the  soft  tissue  in  its  correct  fulness  and  contour.  When  the  loss  of  bone 
of  the  mandible  is  very  extensive,  the  fragments  are  maintained  as  far  as  possible 
in  their  correct  positions  by  dental  splints  while  awaiting  a  bone-graft  operation. 
This  applies  particularly  to  the  posterior  fragment,  which  if  not  so  maintained 
will  cause  a  marked  deformity  by  the  falling  in  of  the  soft  tissues  in  the  region 
of  the  angle.  A  dental  splint  is  also  worn  during  and  after  the  bone-graft 
operation,  to  immobilise  the  fragments  and  graft  and  to  preserve  the  teeth  in 
good  occlusion.  For  this  purpose  splints  are  fitted  to  the  teeth  of  the  upper  and 


FIG.  363. — Apparatus  for  forward  replacement  of 
maxilla. 


19(5 


PLASTIC    SURGERY 


lower  jaws  and  fastened  together  with  a  screw  or  some  such  mechanical  device. 
When  there  are  teeth  on  both  fragments  of  the  mandible,  no  difficulty  is  ex- 


FIG.  365. —  Patient  for  whom  the  apparatus  in  pre- 
ceding figures  was  made.  See  also  Case  No.  62f>  in 
section  on  Upper  Lips  (p.  87). 


Fio.  364. —  Prosthetic  replacement  of  pre-maxilla. 

perienced  in  immobilising  them.  Such 
is  not  the  case,  however,  when  there 
is  a  small  and  edentulous  fragment. 
Many  attempts  have  been  made  to 
hold  this  fragment  in  position  by 
means  of  a  flange  fixed  to  the  lower 
splint,  but  the  best  results  have  been 
obtained  by  bringing  down  the  pos- 
terior fragment  at  the  time  of  the 
operation  and  fixing  it  by  means  of 
the  graft.  Early  movement  has  been 
advocated  and  found  efficient  in  these 
cases,  and  to  facilitate  this  movement  in  instances  where  it  is  impossible  to  fix 
both  fragments  mechanically  with  a  splint,  it  has  been  found  of  great  value  to 
have  a  guiding  flange  fitted  on  to  the  splint 
on  the  larger  fragment,  as  shown  in  fig.  366,  so 
as  to  prevent  the  tendency  of  this  fragment  to 
swing  towards  the  smaller  fragment,  and  thus 
put  unnecessary  strain  upon  the  newly  im- 
planted graft.  By  this  means,  movement  can 
be  started  earlier  than  if  the  flange  had  not 
been  fitted. 

With  reference  to  the  importance  of  pre- 
venting the  encroachment  of  the  soft  tissue 
upon  the  dental  suleus,  and  the  consequent 
inability  to  fit  satisfactorily  a  functional  den- 
tare,  many  cases  have  come  under  notice  in 


PROSTHESIS    AND    PALATES 


197 


Fid.  3G7. — Splint    with    flange    to   maintain    Stent   in  position, 
for  the  Epithelial  Inlay. 


which  it  has  not  been  possible  to  prevent  this  encroachment  during  the  early 
stages  of  treatment,  and  these  cases  for  some  time  presented  a  difficult  problem, 
which  was  exaggerated  in  many  instances  by  the  resultant  falling  in  of  the 
soft  tissues.  The  first  attempts  to  reform  the  sulcus  were  by  freeing  the  soft 
tissues  from  the  hard,  and  immediately  fitting  a  splint  or  denture  with  an 
exaggerated  flange  to  push  out  the  soft  tissues.  The  results  of  this  method 
were  far  from  encouraging, 
adhesions  gradually  taking 
place  again.  Recently,  a 
more  successful  method  has 
been  evolved  by  the  Tise  of 
the  epithelial  inlay :  opera- 
tion (modified  Esser).  For 
this  operation  a  prosthetic 
appliance  is  required  for  the 
purpose  of  holding  the  Stent 
in  position  for  the  necessary  period.  As  shown  in  fig.  867,  this  appliance 
generally  consists  of  a  metal  cap  splint  with  a  removable  horizontal  flange  so 
fitted  as  to  maintain  the  Stent  in  position,  and  to  keep  it  in  close  contact  with 
the  surrounding  tissues  to  enable  the  epithelium  to  become  adherent.  In  the 
after-treatment  of  these  operations  it  is  very  important  to  remember  that  at 
no  time  should  the  newly  made  sulcus  be  left  empty,  and,  after  the  removal 
of  the  Stent,  a  denture  carrying  the  necessary  prolongations  must  be  immediately 
inserted,  and  should  be  worn  continuously  for  at  least  three  months,  after 
which  time  experience  has  shown  these  results  to  be  permanent.  In  the  event 
of  loss  of  hard  tissue  in  these  cases,  the  denture  is  made  to  carry  excessive  vul- 
canite to  enable  the  soft  parts  to  be  restored  to  the  normal  contour.  This 
would  not  be  possible  in  many  cases  unless  the  sulcus  had  been  reformed  by 
an  epithelial  inlay,  as  the  pressure  exerted  by  the  soft  parts  would  make  the 
denture  unstable  and  functionless. 

Exaggerated  cases  of  this  type  often  present  themselves.  The  extensive 
loss  of  the  anterior  portion  of  the  maxilla  having  resulted  in  a  considerable 
falling  in  of  the  soft  tissues,  a  marked  deformity  of  the  profile  of  the  face  is 
caused.  The  following  cases  are  typical  : 

1.  Private  M — 


.  On  admission,  it  was  found  that  he  had  an  old  gunshot  wound, 
with  large  loss  of  the  maxilla  and  nasal  structures  and  loss  of  both  eyes.  The  hard  palate 
was  entirely  lost  except  for  a  small  part,  which  included  the  two  posterior  tuberosities  with 
the  intervening  part  of  the  palate.  Both  antra  were  widely  opened,  owing  to  the  absence 
of  the  nasal  and  anterior  walls.  The  soft  tissues  of  the  lip  and  nose  were  adherent  to  the 
small  remaining  part  of  the  palate  as  shown  in  figs.  368  and  369.  The  case  was  seen  by  Major 
1  For  details  of  Stent  and  Epithelial  Inlay  see  pp.  10  and  H. 


198 


PLASTIC    SURGERY 


FIGS.  368  and  369,-Extensive  bony  loss. 


FIGS.  370  and  371.- Prosthetic  replacement  of  loss, 


PROSTHESIS    AND    PALATES 


199 


Gillies,  who  decided  to  free  the  soft  tissues  from  the  small  remaining  part  of  the  palate. 
The  anaesthetic  was  given  through  a  laryngotomy  tube.     A  knife  was  inserted  behind  the 


FIGS,  3  a  and  373. — Showing  bony  loss  and  prosthesis  to  replace  it. 

upper  lip,  and  the  line  of  attachment  of  the  soft  parts,  both  to  the  hard  palate  and  laterally 
to  the  remains  of  the  superior  maxilla,  was  divided 
in  a  vertical  direction  until  the  level  of  the  eye- 
sockets  was  reached.  The  soft  tissues  were  then 
stretched  forward.  At  this  stage  the  case  was 
taken  over  by  the  dental  department  for  the  soft 
parts  to  be  kept  in  the  new  position.  With  the 
patient  still  under  the  anaesthetic,  dental  com- 
position was  forced  up  into  the  gap  made  and 
left  to  harden.  When  .hardened  it  was  removed 
and  the  impression  used  for  making  the  necessary 
permanent  apparatus.  In  the  meantime  another 
piece  of  composition  was  inserted  into  the  gap 
and  left  in  position  to  hold  the  soft  parts  out  while 
the  apparatus  was  being  made.  In  this  case  no 
epithelium  was  used  to  line  the  new  cavity,  and 
great  difficulty  was  experienced  in  permanently 
maintaining  the  soft  tissues  in  their  position,  and 
it  was  only  after  various  mechanical  appliances 
had  been  constructed  to  force  the  soft  tissues 
forward  that  a  happy  result  was  obtained. 

2.  Private  P . — This  case  was  similar  to 

the  above,  but  the  loss  of  bone  was  not  so  great 
(see  figs.  372  and  373).  The  operation  performed 
was  similar,  except  that  a  small  Thiersch  skin- 
graft  was  placed  upon  the  Stent,  and  round  the 
orifice  of  the  cavity  made,  the  cavity  itself  not  FIG.  374.— Result  of  replacement. 


PLASTIC    SURGERY 


being  lined.  Here,  again,  great  difficulty  was  experienced  in  keeping  the  soft  tissues  in 
their  places,  although  not  to  such  an  extent,  as  in  the  former  case.  Fig.  373  shows  the 
denture  with  a  prosthetic  replacement  of  the  bony  tissue  lost. 

3.  Lieutenant  W—  — . — As  in  the  case  of  Private  M ,  there  was  a  very  extensive  loss 

of  bone.  Before  this  patient  came  under  treatment  he  had  undergone  repeated  operations 
for  closing  off  the  oral  cavity  from  the  remains  of  the  nasal  cavities,  which  had  been  entirely 
Muvcssful.  At  the  same  time  he  presented  the  marked  deformity  shown  in  fig.  £86  (p.  2C6), 
and  it  was  impossible  to  reform  the  nose  to  a  satisfactory  result  in  that  condition.  Moreover, 

the  fitting  of  a  really  functional  denture 
was  not  possible.  Judging  from  the  ex- 
perience of  the  above  cases,  it  was  decided 
to  reopen  the  passage  between  the  mouth 
and  the  nasal  cavities  and  replace  the  loss 
of  bone  by  a  prosthetic  appliance.  The 
operation  performed  was  the  same  as  in 
Case  1,  except  for  the  important  difference 
that  the  whole  of  the  cavity  was  lined  by 
means  of  a  skin-graft,  the  cavity  pre- 
senting a  white  appearance  due  to  the 
epithelial  lining  (vide  fig.  375).  The  result 
was  more  than  satisfactory,  and  at  no 

* 


time  has  there  been  any  difficulty  in 
keeping  the  cavity  open.  It  is  interesting 
to  note  that,  with  the  passage  of  time, 
the  implanted  epithelium  becomes  pinkish, 
and  approximates  more  and  more  closely 
to  mucous  membrane. 


These  cases  emphasise  the  fol- 
lowing points  : 

1.  The  necessity  of  restoring 
loss  of  bone  by  a  prosthetic  appliance 
before  attempting  plastic  operations  upon  the  soft  parts  ; 

2.  The  great  advantage  of  the  epithelial  inlay  operation  over  the  old  method  ; 
and 

3.  The  great  aid,  in  making  a  functional  denture,  of  having  a  certain  amount 
of  support  from  the  prosthesis  replacing  the  lost  bone. 

In  none  of  the  above  cases  was  it  possible  for  the  patient  to  wear  a  denture 
before  the  operation  had  been  performed.  At  present  they  are  all  wearing  an 
efficient  appliance. 


Fio.  375. — Cavity  lined  by  Thierscli  graft. 


INJURIES    INVOLVING    THE    NOSE 

In  the  treatment  of  cases  of  laceration  of  the  soft  and  hard  tissues  of  the 
nose,  with  or  without  loss  of  such  tissues,  it  is  often  necessary  to  restore  the 
replaced  tissues  to  their  correct  position  by  prosthetic  appliances.  The  ap- 


PROSTHESIS    AND    PALATES 


201 


pliances   which   may  be  used   are 

very  varied,  but  generally  speaking 

are  of  two  classes  : 

(a)  Intra-oral,  using  the  teeth 

as  the  point  d'appui  ;    or 

(6)     Extra-oral,   i.e.,  where  a 

headpiece  is  used  for  purposes  of 

attachment. 

Wherever  possible,    intra-oral 

appliances  are  preferable,  owing  to 

the  difficulty  experienced  in  obtain- 
ing complete  stability  by  fixation 

to  a  headpiece  and  to  the  discomfort 

often  caused  by  the  pressure  upon 

the  head  exerted  by  headpieces. 
(a)  Intra-oral    appliances. 

Fig.     376     illustrates     a     typical 

apparatus    used    to    support    the 

lacerated   portions   of  the   tissues 

after  surgical  replacement,  which  no.  370.-^!  splint  with  dental  fixation. 

has   been  found  very  successful.      It   should   be   remembered,    however,   that 

this   appliance    should   not   be   used   to   exert   pressure   upon   the   soft   parts, 

but   merely   for   the   purpose   of  supporting   them   in   their  correct  positions. 

Too  much  pressure  will  only  lead   to  ulceration,  and  failure  will  result. 

In  instances  where  the  bridge  of  the  nose  has  been  depressed,  and  the  tip 

of  the  nose  has  been  displaced  upwards,  the  surgeon  calls  for  an  appliance  to 

hold  the  nose  in  its  correct  position 
after  it  has  been  freed.  Fig.  377 
illustrates  a  typical  appliance  used 
for  this  purpose.  The  piricer-like 
portion  holds  the  columclla,  and 
the  necessary  downward  and  for- 
ward pressure  is  exerted  by  means 
of  attachment  to  a  splint  fixed  to 
the  teeth  of  the  upper  jaw. 

In  cases  of  lateral  displacement 
of  the  nose  a  very  similar  appliance 

FIG.    377— Adjustable   nasal   splint   with   dental  fixation.          ^Q    ^^    shovfn    m     fig>    377    is    used, 

pressure  in  these  instances  being  exerted  in  the  necessary  direction  by  a  vulcanite 
pad  being  placed  either  in  the  nasal  cavities  or  on  the  external  surface  of  the  nose. 


PLASTIC  SURGERY 


Fio.  378. — Adjustable  nasal  splint  with  extra-oral  fixation.         FIG.  379. — Obstructed  airway  due  to  loss  of  columella. 


Fios.  380  and  381.— Airway  restored  by  prosthesis. 


PROSTHESIS    AND    PALATES 


203 


(b)  Extra-oral  appliances.  As  mentioned  above,  this  type  of  appliance 
is  used  only  in  cases  where  intra-oral  appliances  are  not  possible,  owing  to  an 
edentulous  or  fractured  upper  jaw. 

Fig.  378  shows  a  type  of  appliance  which  was  used  to  support  the  depressed 
bridge  of  the  nose.  The  nose  was 
surgically  raised,  two  soft  rubber 
plugs  inserted  in  the  nasal  cavities, 
and  attached  to  the  appliance  by 
means  of  silk  brought  out  through  the 
skin  of  the  nose.  Through  a  screw 
attachment  pressure  was  brought  to 
bear  to  hold  the  soft  parts  in  the 
required  position.  This  apparatus  was 
elaborated  for  Major  Gillies  by  his 
American  colleague,  Captain  Ferris 
N.  Smith,  R.A.M.C.  It  will  be  noticed 
that  the  necessary  support  is  obtained 
from  three  vulcanite  pads,  acting  as 
a  tripod  upon  the  forehead  and  cheeks, 

thus  obviating  the  discomfort  caused  by  the  wearing  of  tight  bands  round 
the  forehead,  and  being  a  distinct  improvement  upon  the  Carter  bridge  system 
of  support. 

In  figs.  379,  380,  381,  and  382  is  shown  how,  in  the  absence  of  a  columella, 
a  prosthetic  appliance  can  be  fitted,  which  cariies  out  the  double  purpose  of 
maintaining  the  airway  and  improving  the  appearance,  without  being  unduly 
noticeable. 


FIG.  382. —  The  artificial  columella. 


INJURIES    INVOLVING    THE    EYES 

No  prosthetic  appliances  are  of  any  assistance  in  the  early  treatment  of 
injuries  in  this  region,  except  in  cases  where  they  are  associated  with  fractures 
of  the  maxilla,  involving  the  orbital  plate.  In  these  latter  cases  the  maxilla 
is  often  displaced  downwards,  and  the  prosthetic  appliance  used  for  raising  the 
upper  jaw  also  supports  the  orbital  contents,  and  tends  to  keep  them  in  their 
normal  position. 

When  it  is  necessary  to  epithelialise  the  orbital  cavity,  a  prosthetic  appliance, 
as  shown  in  fig.  383,  is  required  to  hold  in  position  the  Stent  used  in  this  operation. 
It  consists  of  a  vulcanite  cup  so  shaped  as  to  cover  the  Stent  and  hold  it  in 
position  by  attachment  to  a  splint  on  the  teeth  of  the  upper  jaw.  After  the 
removal  of  the  Stent,  it  is  necessary  to  make  a  vulcanite  duplicate  of  it,  and 


204 


PLASTIC    SURGERY 


this  also  is  maintained  in  position  by  the  same  appliance  until  such  time  as  the 

artificial  eye  can  be  fitted. 

Cases  are  often  found  in  which  the  plastic  surgeon  is  able  to  reconstruct  the 

soft  tissues  round  the  eye,  so  that  the 
patient,  who  was  unable,  prior  to  the 
operation,  to  wear  an  artificial  eye,  is 
enabled  to  do  so.  But  although  he  be  able 
to  wear  the  eye,  it  is  sometimes  impossible 
to  reconstruct  the  eyelids,  especially  the 
upper,  so  that  the  eye  bears  the  natural 
appearance.  In  these  instances,  a  great  im- 
provement can  be  effected  by  the  construc- 
tion of  an  artificial  eyelid,  with  eyelashes, 
attached  to  the  artificial  eye,  which  is  held 
by  the  newly-made  socket.  It  is  also  pos- 
sible, in  some  instances,  to  affix  a  ridge  on 
the  outer  surface  of  the  artificial  eye  in  such 

Fia.  383.- Appliance  used  in  epilhelialisation  of     a  way  that  it  will  Support    a   dl'OOping  Upper 

eyelid,  and  so  enhance  the  cosmetic  effect. 

Figs.  384  and  385  illustrate  an  apparatus  (hardly  prosthetic  perhaps)  used  for 

protecting  a  recently-sutured  palate  from  the  movements  of  the  patient's  tongue. 

The  above  instances  illustrate  some  of  the  valuable  seivices  rendered  bv 


Fics.  384  and  385.— Apparatus  to  protect  sutures  from  patient's  tongue  after  closure  of  palatal  deficiency. 

prosthetic  appliances  in  plastic  surgciy,  and  the  extensive  and  varied  nature 
of  such  appliances.  Ihe  apparatus  mentioned  in  this  chapter  are  described 
as  generally  as  possible,  but  it  must  be  borne  in  mind  that  a  critical  consideration 


PROSTHESIS    AND    PALATES  205 

of  the  nature  of  the  injury  and  the  exact  result  aimed  at  is  necessary  in  each 
case.  Scrupulous  care  must  be  exercised  in  the  adjustment  of  details,  if  the 
greatest  possible  benefit  is  to  accrue  from  an  appliance.  Thus,  there  are  many 
slight  variations  of  the  same  appliance,  each  of  which  augments  the  utility  of 
the  apparatus  in  the  successful  treatment  of  injuries,  similar  in  class  but  varying 
in  detail. 

It  must  also  be  borne  in  mind  that  it  is  essential  that  there  should  be  the 
closest  co-operation  between  the  plastic  surgeon  and  the  dental  surgeon  who 
is  to  make  the  prosthetic  appliance.  In  most  cases  it  is  necessary  to  consider 
both  the  surgical  and  the  dental  aspects,  and  it  is  only  by  working  together 
that  the  best  results  can  be  obtained.  — W.  KELSEV  FRY. 

INJURIES    TO    THE    PALATE 

Asa  result  of  a  study  of  a  long  series  of  cases  treated  in  conjunction  with 
Captain  Kelsey  Fry,  M.C.,  R.A.M.C.,  and  a  development  of  the  application  of 
the  Esser  inlay  principle,  the  author  has  come  to  the  conclusion  that  the  problem 
in  palatal  injuries  can  be  much  reduced.  The  essential  problem  here  is  the 
question  of  mastication  :  Is  the  condition  of  the  parts  such  as  permits  the  ap- 
plication of  the  most  efficient  dental  appliance  ?  The  author  is  convinced 
that  the  existence  of  abnormal  oronasal  communications  is  not  a  serious  dis- 
ability ;  it  may  even  prove  of  immense  service  in  the  provisional  support  for 
a  prosthesis.  Provided  that  the  perforation  is  accurately  occluded  by  the 
appliance,  it  is  found  that  the  nasal  cavity  and  antra  are  sufficiently  protected, 
and  that  speech  and  deglutition  are  restored  to  normal. 

In  one  case  of  a  perforation  involving  both  antra,  Captain  Fry  advised 
Major  Seccombe  Hett,  under  whose  care  the  case  was  placed,  to  enlarge  the 
perforation  so  that  a  purchase  for  the  denture  might  be  obtained  from  within 
the  antra.  The  result  was  very  satisfactory. 

Further  to  emphasise  the  supreme  importance  of  the  dental  aspect  in  the 
treatment  of  palatal  injuries,  a  case  is  quoted  in  which  the  author  has  actually 
re-created  an  oronasal  communication  which  had  been  overcome  previous  to 
the  patient's  admission,  with  the  definite  object  of  furnishing  support  for  a 
denture. 

Lieutenant  W-  had  sustained  a  total  loss  of  nose  and  pre-maxilla  (see 
also  p.  200),  and  the  palatal  gap  had  been  cleverly  bridged  in  the  remaking  of 
the  upper  lip,  which  now  hung  from  the  anterior  edge  of  the  remnant  of  the 
palate. 

It  was  not  found  possible  to  fit  a  functional  denture.  The  first  step,  there- 
fore, was  to  free  the  lip  from  its  new  attachment.  This  led  to  a  ringlike  raw 


200 


PLASTIC    SURGERY 


area,  which  was  epithefialised  by  a  Thicrsch  graft  held  in  position  by  moulded 
Stcnt  fixed  to  a  temporary  appliance.  Into  the  resulting  intranasal  prolongation 
of  the  buccal  cavity  a  prosthesis  was  fitted,  made  in  three  pieces  of  vulcanite, 
and  an  efficient  denture  was  made  to  take  origin  therefrom.  An  excellent 
functional  result  went  hand-in-hand  with  a  notable  improvement  in  the  ap- 
pearance (figs.  386  and  387). 

As  in  all  facial  injuries,  a  successful  repair  in  this  region  depends  on  meti- 
culous care  in  the  diagnosis.  The  loss  in  each  layer  of  the  palate,  and  the  direc- 
tion of  any  displacement  together  with  the  factors  which  maintain  it,  must 
be  accurately  determined  by  oral,  intra-nasal,  and  radiographic  examination. 


FIG.   38f>. — Soft  tissues  adherent  to  remains  of 
palate  after  closure  of  oronasal  communication. 


Fio.   387. —  Oronasal  communication  restored. 
Prosthetic  replacement  of  bcny  loss. 


These  injuries  bear  a  superficial  resemblance  to  congenital  deformities,  but 
the  problem  is  essentially  different.  There  is  actual  loss  of  hard  tissue,  not 
mere  failure  of  union  ;  and  mastication,  rather  than  speech  and  deglutition, 
is  the  first  aim  in  repair. 

The  first  consideration,  therefore,  is  the  provision  of  a  dental  appliance 
which  must  not  merely  replace  the  structural  loss,  but  should  ensure  efficient 
mastication. 

From  the  standpoint  of  treatment,  these  injuries  may  be  divided  as  follows  : 
1.  Those  involving  chiefly  the  pre-maxilla  and  alveolar  border. 

Ixperience  has  shown  that  these  cases  are,  in  essence,  in  the  province  of 
the  dental  surgeon.  Certain  important  preliminaries  may  have  to  be  completed 
by  the  plastic  surgeon  before  the  case  is  handed  over.  For  instance,  an  adherent 


PROSTHESIS    AND    PALATES  207 

lip  or  cheek  may  require  liberation  with  epithelialisation  of  the  resulting  raw 
area,  before  the  dentist  has  any  chance  of  fitting  a  masticatory  appliance. 
Cases  also  occur  where  an  ill-advised  closure  of  a  palate  gap  has  been  performed, 
and  the  surgeon  is  faced  with  the  repellent  necessity  of  undoing  the  good  work 
of  his  predecessor,  in  order  that  the  task  of  the  dentist  may  be  rendered  possible. 

2.  Injuries  leading  to  large    or  small  hard-palate   perforations,  which  do 
not  involve  the  alveolar  border. 

Here  the  surgeon  feels  justified  in  attempting  closure.  The  intact  alveolar 
ridge  gives  promise  of  adequate  support  for  any  denture  which  may  be  indicated  : 
there  is  no  need  of  the  mechanical  advantage  offered  by  the  perforation. 

3.  Lateral  anterior  defects  involving  the  alveolus.     Here  the  disposal  of 
the  case  rests  on  the  question  of  the  existence  of  teeth  on  the  fragments  bordering 
the  gap.     If  good  teeth  are  present  on  both  edges,  closure  may  be  undertaken 
in  the  knowledge  that  the  dental  surgeon  has  adequate  support  for  the  application 
of  a  masticatory  appliance. 

If  teeth  are  lacking — a  condition  usually  co-existent  with  a  levelling  of 
the  alveolar  ridge — then  there  is  need  of  any  and  every  nook  and  cranny  as 
possible  purchase  for  the  denture,  and  since  mastication  is  the  prime  necessity, 
the  surgeon  must  limit  himself  to  the  dental  needs  of  the  case. 

4.  Injuries   involving   the   soft   palate.     There   need   be   no   hesitation   in 
repairing  soft-palate  injuries  forthwith.     The  mobility  of  the  part  precludes  its 
being  of  use  as  a  point  d'appui. 

Methods  of  repair  used. — So  varied  are  these  injuries  in  quantity  and  degree, 
that  few  methods,  both  classical  and  those  hitherto  unknown,  have  escaped 
a  thorough  trial,  including  at  least  two  methods  believed  by  the  author  to  be 
original.  Lane's  double-flap  method  has  given  good  results  in  the  author's 
hands,  where  flaps  have  been  available,  and  the  Von  Langenbcck  principle 
has  proved  satisfactory  in  cases  where  the  state  of  the  parts  permitted  the 
advancement. 

The  author  has  seen  cases  of  successful  results  from  the  use  of  large  mucous 
membrane  flaps  from  the  cheek.  In  selected  cases,  these  would  seem  to  be 
ideal. 

Working  in  conjunction  with  Major  Seccombe  Hett,  the  author  has  on 
several  occasions  made  use  of  the  inferior  turbinate  as  a  partial  or  complete 
obturator.  This  bone  is  separated  from  its  attachment  in  part  of  its  length 
and  is  swung  down  on  the  pedicle  of  what  remains. 

Its  double  covering  of  mu co-periosteum  makes  it  peculiarly  adapted  for 
the  purpose,  and  its  phenomenal  blood-supply  enables  it  soon  to  establish  con- 
nection with  the  rawed  edge  of  the  palate.  Its  attached  end  can  be  safely 
severed  in  about  ten  days,  and  brought  down  to  assist  in  the  closure. 


208  PLASTIC    SURGERY 

The  author  has  applied  his  tube-pedicle  method  in  this  connection,  and 
large  perforations  have  been  closed  with  skin  from  the  neck  and  chest  by  this 
means,  in  cases  where  coincident  cheek  loss  has  permitted  the  intrusion  of  the 
pedicle.  Indeed,  if  need  be,  it  is  probable  that  there  is  no  gap  which  could  not 
be  closed  by  this  method.  Were  closure  imperative,  access  for  the  pedicle 
could  be  obtained  by  temporarily  enlarging  the  mouth. 

Summarising,  therefore  :  First,  a  critical  examination,  with  a  view  to 
accurate  determination  of  the  loss,  then  a  consultation  with  the  dental  surgeon 
as  to  the  advisability  of  surgical  interference.  (Shall  the  defect  be  covered, 
left  alone,  or  even  enlarged  ?)  And,  finally,  a  consideration  of  the  surgical 
possibilities  of  closure,  bringing  under  review  the  approach  to  the  injury,  the 
flaps  available,  the  viability  of  the  parts  involved. 


INJURIES    OF  THE  NOSE 


14 


CHAPTER    VI 
INJURIES    OF    THE    NOSE 

IT  is  not  proposed  to  give  a  full  historical  outline  of  rhinoplasty.  Noses  have- 
been  made  since  the  very  earliest  times,  and  most  of  the  methods  possible— 
and  impossible — have  been  tried  on  isolated  cases.  No  one  man  has  ever, 
previously,  had  sufficient  material  to  elevate  this  branch  of  surgery  from  its 
unfavourable  status,  which  has  been  so  aptly  summed  up  by  the  French  in  their 
saying  "  before  he  was  horrible  :  now  he  is  ridiculous."  Artificial  noses  have, 
therefore,  been  developed  to  a  far  greater  extent  in  the  past  than  has  the  operation 
of  rhinoplasty.  How  is  it,  then,  that  one  is  now  in  a  position  to  state  that  in  any 
given  case  of  rhinoplasty  it  is  probable — almost  certain — that,  following  operative 
procedures,  the  patient  will  have  a  result  that  looks  like  a  nose — one  that  has  good 
circulation,  good  colour,  and  a  good  airway  ?  The  answer  is  manifold. 

The  ravages  of  war  have  enabled  a  large  number  of  cases  to  be  collected 
under  one  team  of  surgeons.  The  various  methods  have  been  tried  and  sifted 
until  a  satisfactory  combination  has  been  developed. 

The  great  principle  of  providing  all  three  elements  of  the  nose — skin,  support- 
ing structure,  and  epithelial  lining — has  been  enunciated.     In  order  to  arrive  at 
a  satisfactory  reconstruction,  diagnosis  must  be  made  of  the  independent  loss  of 
each  of  these  three  elements.    When  it  is  known  exactly  what  there  is  to  replace, 
both  in  quality  and  quantity,  the  problem  of  the  restoration  becomes  simplified. 
Among  the  following  cases  arc  shown  some  good  and  some  bad  results. 
The  first  entire  nose  constructed  by  the  author  was  lined  with  mucous  membrane, 
without  realising  that  it  had  been  done.     The  next  nose  was  made  without 
such  lining,  and  the  unfortunate  result  led  one  to  seek  the  cause  of  failure.     From 
that  day  no  nose,  or  portion  of  a  nose,  has  been  made  here  without  its  adequate 
skin  or  mucous  lining,   and  the  whole  status  of  rhinoplasty,   as  practised  by 
author  and  colleagues,  has  since  that  day  undergone  a  change  which  is  truly 
remarkable.     Although  the  necessity  for  this  nasal  lining  was  recognised  quite 
independently,  one  must  pay  great  tribute  to  the  rhinoplastic  work  of  Kcegan 
in   India.     For  the  Indian  type  of  mutilation  (where  an  unfaithful  husband  or 
wife  is  punished  by  cutting  off  the  soft  parts  of  the  tip  of  the  nose)  Keegan  and 
his  follower,  Smith,  designed  exact  inturned  flaps  to  line  the  tip  and  the  alae. 

The  author  had  recognised  that  all  noses  must  be  skin-lined,  but  on  digest- 
ing Keegan's  written  work  one  was  absolutely  convinced  that  this  is  the  right 
principle.  His  particular  flaps  are  applicable  only  to  the  loss  of  the  lower  third, 
or  fleshy  part  of  the  nose.  But  the  principle  has  been  extended  and  modified  until 
all  types  of  loss  can  be  successfully  restored.  Prior  to  this  review  of  the  Keegan- 
Smith  operation,  the  author  had  been  confronted  with  a  very  great  difficulty  in 
the  " pug-nose  :'  deformity.  After  several  failures,  one  was  fortunate  enough 

211 


PLASTIC    SURGERY 


to  evolve  a  principle  which  not  only  produced  a  definite  cure  for  this  deformity, 
but  is  also  applicable  to  many  other  restorations.  This  particular  flap  has  been 
fully  described  in  the  chapter  on  Principles.  So  much  for  the  lining  membrane. 

In  regard  to  the  supporting  structure,  free  cartilage  implantations,  both 
autologous  and  homologous,  are  freely  used.  The  cartilage  may  be  put  in 
prior  to  the  rhinoplasty,  in  either  the  external  flap  or  in  the  internal  flap,  or 
it  may  be  interposed  between  the  two  flaps  at  the  time  or  subsequent  to  the 
rhinoplasty.  The  best  time  for  such  implantation  varies  with  the  type  of  case, 
but  the  author  is  convinced  that  the  imbedding  of  the  cartilage  in  the  flap  that 
is  to  make  the  external  covering  is  an  entire  mistake. 

Occasionally  the  best  result  will  be  obtained  by  implanting  the  cartilage 


Fio.  388. — Diagram  to  show  the  author's  skin- 
cartilage  awing  to  replace  and  retain  the  tip  in  position, 
and  to  provide  skin-lining  for  the  bridge  and  alse. 


FIG.  389. — Position  of  the  skin -cartilage  flaps  after 
they  have  been  reversed.  Tube-pedicle  chest-flap  is 
represented  on  its  way  to  the  nose. 


between  the  lining  and  the  skin-flap  at  the  time  of  rhinoplasty ;  but  the  author's 
principle  of  imbedding  the  desired  cartilage  in  the  inturned  flap  seems  the  most 
scientific  and  best  method.  It  is  nearly  always  necessary  to  superimpose 
further  cartilage  at  a  later  date.  This  must  be  done  with  great  care,  as  on  one 
occasion  a  very  good  nose  was  spoiled  by  unduly  stretching  the  new  skin.  The 
other  method  employed  by  the  author  for  obtaining  supports  is  one  which  in- 
volves the  grafting  into  the  desired  position  portions  of  the  septum  or  turbinates 
of  the  nose,  and  in  certain  cases  much  help  is  obtained  from  these  transplanta- 
tions. Further,  mechanical  supports  through  an  existing  palatal  orifice  have 
been  used  by  the  author  in  syphilitic  cases,  after  providing  the  other  two 
necessary  elements  of  the  skin  and  lining  membrane. 


INJURIES    OF    THE    NOSE 


213 


The  external  covering  presents  fewer  features  of  interest.  It  may  be 
obtained  from  the  arm,  the  cheek,  the  forehead,  or  from  the  chest — by  the 
author's  pedicle.  See  figs.  389  and  390.  From  these  methods  the  best-looking 
nose  is  undoubtedly  that  which  is  made  from  the  forehead  skin  ;  the  sebaceous 
and  greasy  nature  of  the  skin,  together  with  its  colour,  render  it  more  like  nasal 
skin  than  that  from  any  other  part.  Recently,  an  attempt  has  been  made  to 
provide  the  skin  covering  by  a  whole-thickness  free-graft  taken  from  the  inner 
side  of  the  arm  ;  but,  although  this  procedure  is  not  yet  completely  proven  to  be 
a  successful  method,  it  seems  certain  that  it  will  shortly  be  an  established  prin- 
ciple. In  the  author's  opinion,  an  exact  pattern  of  the  raw  area  to  be  covered 
should  be  made  of  tin-foil  and  the  flap  from  the  forehead  cut  exactly  to  shape. 


FIG.  390. — Rhinoplasty  from  chest,  author's  tube-pedicle  method 

The  tin-foil  model  is  made  a  little  smaller  than  the  raw  area  in  order  that  the  flap 
should  be  on  natural  tension.  One  has  seen  a  great  number  of  constructed  noses 
the  fat  and  clumsy  appearance  of  which  is,  in  my  opinion,  due  to  cutting  the  flap 
larger  than  necessary,  to  "  allow  for  contraction."  One's  opinion  is  that  no 
contraction  can  occur  if  the  correct  skin  lining  and  supporting  structures  have 
been  provided. 

The  treatment  of  stenosis  of  the  anterior  nares,  due  to  imperfect  rhinoplasty, 
has  been  successfully  dealt  with  by  means  of  the  Esser  epithelial  inlay.  Many 
other  types  of  stenosis  are  present  as  a  result  of  gunshot  injury.  When  the 
author  undertook  the  problem  of  complete  rhinoplasty,  his  first  ambition  was 
the  production  of  noses  which  had  an  absolutely  clear  airway.  Consequently, 
many  operations  are  frequently  necessary  to  clear  such  airway  before  the 


214  PLASTIC    SURGERY 

reconstruction  is  commenced.  The  principle  of  sewing  skin  to  mucous  membrane 
round  the  margin  of  an  aperture  is  a  very  sound  one  and  prevents  contraction. 
The  method  of  dealing  with  the  restoration  by  means  of  a  "  Vallancey  swing," 
has  the  inestimable  advantage  of  giving  such  access  to  the  nasal  cavity  that 
the  debris  of  the  injury  can  be  successfully  removed — debris  which  could  not 
possibly  be  attacked  through  the  anterior  nares. 

ILLUSTRATIVE  CASES 

The  following  cases  have  been  arranged  into  groups  according  to  the  site  and  extent  of 
the  injury : 

GROUP  I  represents  the  minor  injury  of  loss  of  the  upper  quarter  of  the  bridge  of  the  nose. 

In  GROUP  II  the  upper  half  of  the  nasal  bridge  has  been  destroyed,  producing  a  type 
of  nose  that  one  might  call  the  "bird  beak." 

GROUP  III  comprises  cases  where  the  bony  ridge  has  been  broken  or  destroyed  :  in  these 
the  tip  still  remains  in  fairly  normal  position,  and  the  bridge  is  flattened,  but  there  is  no 
important  loss  of  the  lining  membrane. 

GROUP  IV  deals  with  cases  where  the  middle  of  the  nose  has  been  destroyed  or  crushed, 
and  is  accompanied  by  tilting  of  the  tip  (pug-nose  type)  and  considerable  loss  of  the  lining 
membrane. 

Under  GROUP  V  have  been  collected  the  Indian  mutilation  type,  together  with  various 
cases  showing  loss — partial  or  complete — of  the  structures  of  the  lower  third  of  the  nose, 
including  the  tip  and  ala1. 

GROUP  VI. — In  this  are  cases  of  loss  of  the  lower  two-thirds  of  the  nose,  i.e.  they  are 
practically  cases  for  complete  rhinoplasty  save  that  a  small  portion  of  the  bony  bridge 
re-mains. 

GROUP  VII. — Total  loss  of  the  nose,  and,  in  some  cases,  with  loss  of  the  bed  on  which 
the  nose  is  built. 

Hums  of  the  nose  have  been  described  in  a  separate  chapter. 

GROUP  I 

NOSES,    SHOWING    THE    LOSS    OF    THE    UPPER    QUARTER    OF 

THE    NASAL    BRIDGE 

This  class  of  case  is  simple  to  treat  in  a  number  of  ways,  and  a  number 
of  methods  are  available. 

The  two  cases  illustrated  have  been  treated  by  one  method,  the  principles 
of  which  are  the  following  : 

The  skin  covering  is  supplied  by  advancing  flaps  from  the  neighbourhood— 
usually  the  glabellar  region,  the  supporting  structure  is  provided  by  the  turn 
down  of  an  osteopcriosteal  flap  from  the  glabellar  region,  while  the  skin  lining 
is  disregarded. 

The  reason  for  the  latter  is  that  the  apertures  into  the  nose  arc  so  small 
that  they  may  be  frequently  obliterated  by  suture,  or,  if  not  amenable  to  this 
treatment,  t  heir  continued  existence  at  such  a  high  point  of  the  nasal  cavity  does 
not  lead  to  infection  and  uleeration  of  the  supporting  structure. 


INJURIES    OF    THE    NOSE 


215 


CASE  30 

In  addition  to  the  loss  of  the  upper  quarter  of  the  nasal  bridge,  this  man  had  lost  his 
left  eye.  The  covering  was  obtained  by  a  straight  advancement  of  the  skin  over  the  glabellar 
region — flap  A. 

After  excision  of  scar  at  the  bottom  of  the  depression  only  a  small  opening  into  the 
nose  remained.  This  was  partly  obliterated  by  suture.  The  small  osteoperiosteal  flap 


FIG.  391. — The  healed  condition. 


FIG.  392. — Result  :   note  absence  of  artificial  eye. 


was  turned  down  and  sutured  to  the  back  of  the  existing 
bridge. 

Details  of  this  operation  are  appended. 

7.7.1G.  Operation.— A.  "U  "-shaped  flap,  with 
its  base  upwards,  was  dissected  off  the  frontal  bone, 
and  a  wedge  of  this  bone  turned  down  reverse  side 
uppermost  so  that  it  met  the  existing  bridge.  An 
attempt  was  made  to  stitch  it  in  this  position  with 
catgut.  A  portion,  however,  was  broken  in  the  pro- 
cess. The  frontal  skin-flap  was  brought  down  to  meet 
the  existing  skin  of  the  nose  and  the  wound  closed. 

13.8.16.  Result. — A  small  broken  piece  of  the 
frontal  graft  was  exfoliated  ;  otherwise,  normal  healing 
and  the  very  satisfactory  result  from  a  cosmetic  point 
of  view. 


Fia.     3  93. — Osteoperiosteal    flap    turned 
down  from  glabella.      No  skin. lining. 


PLASTIC    SURGERY 


CASE  87 

Shows  an  injury  caused  by  a  transverse  bullet- wound.     The  eyes  escaped  damage. 
Tin-  only  difference  in  this  case  was  that  the  flap  from  the  glabellar  region  was  secured  by 

means  of  an  oblique  swinging  advance- 
ment. Lines  of  the  scar  after  operation 
are  shown  in  the  photograph,  fig.  395. 
The  osteoperiosteal  flap  was  turned  down 
in  the  same  manner  as  in  the  previous 
case,  and  the  details  of  the  operation  are 
appended. 

1.1.17.  Operation. 

METHOD  OF  TREATMENT. — 1.  Sliding 
flap  from  forehead  to  provide  skin.  2. 
Hony  support  formed  by  turning  down 
osteoperiosteal  flap  from  the  forehead. 

PLASTIC  OPERATION. — Scar  tissue 
excised ;  large  oblique  frontal  flap  turned 
up.  Two  vertical  incisions  through 
periosteum  in  line  with  nose.  Small 
plate  of  bone  chiselled  orf  between  these 
incisions,  and  bone,  with  periosteum, 
lifted  and  turned  downwards  over  bridge 
and  sutured  into  place.  Skin-flaps  ap- 
proximated over  all. 


Fir..   :!!)4. — Loss  of  upper  quarter  of  bridge—  bullet  wound. 


Fio.  39.1.— Shows  result.  The  oblique  swinging 
frontal  flap  can  be  distinguished  in  its  sutured 
position. 


Fio.  39C>. — Kesult.     Vartial  side  view. 


INJURIES    OF    THE    NOSE  217 


GROUP  II 

When  this  loss  of  the  bridge  is  of  a  more  extensive  character,  what'  one  has 
called  the  loss  of  the  upper  third  or  upper  half  of  the  nasal  bridge — the  bird-beak 
class — this  method  of  osteoperiostcal  support  is  not  sufficiently  firm,  and  has 
not  been  used. 

1  he  ideal  method  for  this  repair  consists  of  the  implantation  of  the  necessary 
cartilage  in  an  adjacent  skin-flap  (the  glabclla  usually)  as  the  first  stage.  Sub- 
sequently this  cartilage  and  skin-flap  are  swung  down  together,  and  the  necessary 
covering  provided  from  the  forehead.  With  loss  in  this  situation  it  is  not  neces- 
sary to  divide  the  repair  into  two  stages,  and  the  cartilage  may  be  imbedded 
between  the  two  flaps  at  the  time  of  operation.  lhe  author  has  no  case  to 
illustrate  this  method.  In  one  of  the  cases  following,  the  support  and  lining 
were  provided  by  a  septal  swing,  followed  by  a  later  implantation  of  a  cartilage 
rod.  I  his  gave  a  sufficiently  satisfactory  result,  lhe  skin  covering  was  pro- 
vided by  advancement  flap  from  the  cheeks — a  bad  method  as  a  rule.  In  the 
other  case  no  epithelial  lining  was  provided,  and  the  support  was  an  osteo- 
periosteal  graft  from  the  tibia,  while  the  skin  covering  was  provided  by  an 
advancement  of  the  skin  between  the  eyebrows,  lhe  result  was  a  partial 
failure,  and  the  method  is  obsolete  because  no  epithelial  lining  is  provided. 


218 


PLASTIC    SURGERY 


CASE  268 

In  this  case  the  loss  of  tissue  comprised  : 

1.  The  nasal  bones,  underlying  portion  of  septum,  frontal  spine,  and  upper  portions 
of  nasal  process  of  superior  maxillae. 

2.  The  skin  that  should  cover  this  part  of  the  nose. 

3.  The  right  eye. 

There  was  a  small  opening  into  the  nose  surrounded  by  scar  tissue  and  granulations, 
which,  when  excised,  left  a  bare  area  of  about  ^  in.  square. 

4.6.16.  First  operation. — Excision  of  scar,  and  submucous  resection  of  a  piece 
of  the  perpendicular  plate  of  the  ethmoid,  which  was  swung  forward  to  form  a  bridge,  and 
sutured  below  to  the  septum  of  the  lower  nose  with  catgut.  Two  sliding  lateral  flaps  from 
the  cheek  were  cut,  undermined,  and  sutured  over  this  bridge  with  fine  interrupted  silk 
(vide  fig.  399). 

Result, — Slight  breaking  down  near  the  angle  of  the  right  eye,  which  socket  was  not 
entirely  clean.  Primary  healing  of  the  rest,  with  excellent  cosmetic  results.  As  antici- 
pated, the  bridge  gradually  sank,  as  the  bridge  of  septal  cartilage  was  not  strong  enough 
to  support  the  contracting  skin  flaps. 

3.9.16.  Second  operation. — Gas  and  oxygen  anaesthesia  by  Capt.  II.  E.  G.  Boyle, 
who,  on  a  visit,  kindly  gave  a  very  satisfactory  demonstration  of  this  method. 

Small  skin  incision  ;  skin  very  carefully  undermined  from  below  upwards  until  the 
frontal  bone  was  reached,  when  the  depth  was  increased,  and  the  periosteum  incised  and 
raised.  A  piece  of  rib  cartilage  of  the  necessary  length  was  cut,  fashioned,  and  inserted 
under  the  skin  and  periosteum,  its  lower  end  resting  on  the  cartilage  of  the  lower  part  of 
the  septum.  Catgut  ligatures  were  inserted  to  hold  it  central,  but,  as  the  photos  taken 
two  months  after  show,  the  lower  end  slipped  off  the  cartilage  and  produced  a  slight  de- 
formity. 

With  the  fitting  of  an  artificial  eye  the  result  was  very  satisfactory. 


Kin.  397.— Loss  of  upper  half  of  bridge. 


Fio.  398. — Result,  two  operations.  Xote  the  slipping 
of  the  lower  end  of  the  cartilage  rod  off  the  septum. 
The  fixation  of  a  cartilage  implant  is  most  important. 


INJURIES    OF    THE    NOSE 


219 


FIG.  399. — Diagrams  showing  incisions,  flaps,  and  suture  of  first  operation.     Note  the  wire  retention  suture 
from  cheek  to  cheek,  and  the  septal  advancement  as  a  support.     4.0.10. 


FlO.  400. — Profile   before. 


FIG.  401. — Profile  after  plastic  and  cartilage  implant. 


220 


PLASTIC    SURGERY 


CASE  125 

This  was  a  case  of  a  similar  condition.  In  its  repair,  both  skin-flaps  and  the  supporting 
structure  were  different  from  the  previous  case. 

In  regard  to  the  skin-flaps,  the  diagrams  illustrate  their  use.  The  glabclla  flap  A  was 
advanced  to  meet  the  nose  (A1),  while  two  lateral  flaps  (B  and  C)  were  advanced  to  meet 
the  sides  of  A.  In  order  to  close  the  nasal  opening,  a  flap  of  periosteum  only  was  turned 
down  beneath  A,  see  fig.  406.  Supporting  structure  was  furnished  by  a  bridge  of  thin  osteo- 


Fio.  402. — Loss  of  upper  half  of  nose. 


FIG.  403. — The  skin-flaps.     A  is  advanced  to  A'.\ 


Flo.   404.— Suture. 


Fia.  405. — Early  result.     Xote  relaxation  button. 


INJURIES    OF    THE    NOSE 


221 


periostcal  graft  from  the  tibia.  It  extended  from  the  glabellar  region  to  underneath  flap  A1, 
which  was  undermined. 

The  immediate  result  of  this  procedure  was  very  satisfactory,  but,  owing  to  the  failure 
of  the  supporting  structure  to  consolidate,  the  bridge  fell  in,  and  contraction  and  retraction 
occurred. 

In  addition  to  the  new  bridge  partly  collapsing,  the  tip  of  the  nose  was  slightly  drawn 
up.  Most  of  this  failure  was  determined  by  the  absence  of  epithelial  lining. 

This  case  is  published  because  it  shows  many  interesting  features  to  avoid.  A  better 
method  for  this  particular  case  would  have  been  as  follows  : 

First  stage. — Cartilage  of  necessary  length  to  complete  bridge  imbedded  in  glabellar 
region. 

Second  stage. — This  flap  and  cartilage  turned  down,  skin  surface  inwards,  and  covered 
by  a  transposed  frontal  flap. 

Note. — Big,  straight  advancement  from  the  frontal  region,  as  is  evidenced  in  this  case, 
does  not  give  a  satisfactory  result,  although  the  smaller  ones  on  Cases  87  and  30  are  quite 
satisfactory. 

Details  of  Case  125  are  appended. 

13.2.17.  Plastic  Operation. — The  scar  tissue  surrounding  the  sinus  into  the  nasal 
cavity  was  removed.  Two  incisions  were  made  upwards  on  to  the  forehead  forming  a  flap. 
Two  more  on  either  side  were  made  running  outwards  on  to  the  face,  forming  another  flap 
on  each  side. 

A  piece  of  periosteum  was  turned  down  from  the  frontal  bone  and  the  end  placed  over 
sinus. 

Another  piece  of  periosteum,  with  a  slight  amount  of  bone  attached,  about  2  in.  by 
1  in.,  was  removed  from  front  of  right  tibia  and  laid  lengthwise,  extending  from  forehead 
nearly  to  tip  of  nose.  Skin-flaps  approximated,  as  in  fig.  404. 


Flo.  4!)(i. — Shows  indifferent  final  result  of  this  method,  due  to  the  failure  to  provide  an  epithelial  lining  to  the  new 
portion  of  nose.  Contraction  and  retraction  have  occurred.  The  diagram  indicates  the  construction  of  the  lining,--- 
periosteum  only. 


PLASTIC    SURGKHY 


GROUP  III 

Depression  or  destruction  of  the  bridge  of  the  nose  without  distortion  of 
the  tip  or  serious  loss  of  the  lining  membrane.  These  cases  are  amenable  to  a 
restoration  by  implantation  of  a  new  cartilaginous  bridge. 

1  he  last  of  this  group  really  belongs  to  Group  IV,  but,  as  it  was  treated  on 
lines  laid  down  as  efficient  for  Group  III,  it  is  included  here.  Ihe  indifferent 
result  obtained  in  this  case  is  due  to  the  fact  that  one  did  not  realise  that  there 
was  serious  loss  of  the  epithelial  lining. 


CASE  171 

The  injury  to  this  officer  was  due  to  a  crash  in  an  overturned  motor-bus  at  the  Front. 
In  addition  to  the  whole  bridge  of  the  nose  being  driven  in,  he  suffered  a  depressed  fracture 
of  the  frontal  bone.  He  was  admitted  for  plastic  treatment  of  the  resultant  deformity. 
A  double  cartilage  implantation  was  made,  one  to  the  bridge  of  the  nose  and  a  smaller 
piece  in  the  depression  over  the  frontal  bone.  This  was  an  early  case,  and  one  did  not 
appreciate  the  fact  at  that  date  that  cartilage  remains  the  same  size  as  when  implanted. 
Allowance  was  made  for  some  absorption,  which,  however,  did  not  occur.  The  profile 
restoration  was  good,  except  in  the  neighbourhood  of  the  glabclla.  and  the  general  appearance 
was  markedly  improved.  There  was  a  slight  displacement  of  the  small  plate  of  cartilage 
inserted  in  the  depressed  fracture  of  the  frontal  bone,  and  the  nasal  cartilage  was  a  little 
too  thick  and  too  long.  The  cartilage  for  this  restoration  should  be  cut  to  the  exact  size 
necessary,  and  should  be  most  efficiently  anchored  into  position  by  catgut  sutures  or  by 
tucking  it  under  some  periosteal  flap.  The  slight  deformity  remaining  could  most  efficiently 
and  easily  be  cured  by  simple  excision  of  the  redundant  portion  of  cartilage;  but  the  pressure 
of  war  has  prevented  this  officer  from  having  this  correction  made.  It  is  a  mooted  point 
whether  this  bridge  could  not  have  been  raised  by  sub-mucous  division  of  the  nasal  supports 
combined  with  a  Carter  type  of  bridge  elevation.  The  frontal  depression  would  have 
required  separate  correction.  Details  of  operation  are  appended  : 

31.3.17.  ()]>i'r(itii>n. — Semilunar  flap,  with  convexity  downwards,  lifted  from  root 
of  nose  ;  small  periosteal  and  bone  flap  chiselled  upwards,  creating  a  notch  to  serve  as 
support  for  graft.  Skin  over  dorsum  of  nose  down  to  tip  separated  from  underlying  tissues 
by  undercutting,  through  original  incision. 

Cartilage  graft. .'i  in.  in  length,  taken  from  7th  costo-stcrnal  junction  in  the  right  thorax, 
shaped,  and  inserted  beneath  skin  and  underlying  tissues  of  nose  as  far  as  the  tip  and  tucked 
in  beneath  the  periosteal  flap  above. 

.Siiuill  frontal  scar  separated  from  its  deep  adhesions  by  undercutting  through  original 
frontal  sear,  and  a  small  piece  of  cartilage  sutured  in  position. 


INJURIES    OF    THE    NOSE 

ON  ADMISSION 


223 


Fid.  407.— Full  face.  FIG.  408.—  Profile. 

9 

AFTER   CARTILAGE   IMPLANTS 


FIG.  409. — Full  face. 


FIG.  410.— Profile. 

Note  :   the  prominence  in  the  glabellar  region  can  bo 
easily  dealt  with  by  excision  of  redundant  cartilage. 


•_".'  t 


PLASTIC    SURGERY 


C.'.SK  102 

This  case  shows  loss  of  all  the  lower  portion  of  the  nasal  supports,  and  the  interest 
of  the  ease  rests  in  the  successful  application  of  dental  nasal  splints  as  a  preliminary  measure. 
Had  this  splint  been  available  a  few  hours  after  the  receipt  of  the  injury,  it  is  possible  that 
the  restoration  by  this  means  might  have  been  even  more  perfect.  It  is,  however,  to  be 
recognised  that  there  is  loss  of  the  external  skin  and  epithelial  lining  and  of  the  septal  sup- 
ports. Therefore,  no  mechanical  restoration  could  have  been  perfect.  A  very  nice-looking 
and  satisfactory  nose  was  obtained,  as  a  result  of  cartilaginous  implantation,  but  it  is  not 
a  restoration  to  the  normal,  because  no  provision  was  made  for  the  accompanying  loss  of 
lining  membrane.  It  is  especially  to  be  observed  that,  despite  the  satisfactory  restoration, 
the  alie  are  drawn  up  on  each  side  and  the  tip  is  still  somewhat  depressed. 

In  regard  to  this  cartilaginous  implantation,  it  is  the  first  time,  as  far  as  the  author  is 
aware,  that  a  piece  of  cartilage  was  used  down  the  columella  to  prop  up  the  bridge  cartilage 
and  the  tip.  This  method  of  supporting  the  tip  has  become  almost  a  standard  practice  in 
the  later  development  of  our  rhinoplastics.  Operation,  etc.,  notes  given  below  : 

Restoration  of  the  nose  by  splint  and  cartilage  graft.  .  .  .  Wounded  on  20.12.16. 
The  condition  on  admission,  nine  days  later,  to  the  Cambridge  Hospital,  Aldershot,  is  shown 


FIGS.  411  and  412.— On  admission. 

in  figs.  411-412;    the  anterior  part  of  the  septum,  with  portions  of  both  alse.  having  been 
shot  away,  a  considerable  flattening  of  the  nose  resulted. 

15.1.17.    /•'/;•*/    operation— 1\\c   flattened   portions   having   been    freed    of    all    their 

adhesions,  the  apparatus  shown  in  fig.  413  (drawn  by  Professor  H.  Tonks),  (made  by  Captain 

King  and  staff)  was  inserted.     '\  his  was  continuously  worn  by  the  patient  for  seven 

weeks   and  produced  a  very  considerable  improvement,  as  sliown  in  fig.  414.     Figs.   H 5-416 

•  later  and  permanent  result  of  the  insertion  of  a  graft  3  in.  in  length,  taken  from 

the  eighth  rib.  to  raise  and  support  the  lower  part  of  the  nose.     The  cartilage  was  inserted 

in  two  Portions  through  the  columella;  the  longer  portion  was  pushed  in  beneath  the  skin 

rm  the  bridge,  while  a  shorter  piece  was  imbedded  down  the  columella  towards  the 

i  so  as  to  support  the  tip  of  the  nose.     Plastic  re-suture  of  the  ala;  to  give  symmetrical 

iranee  was  carried  out  at  the  same  operation.     To  Captain  Kclsey  Fry,  MX'.,  belongs 

t  nl  giving  the  nasal  splint  the  prolonged  trial,  which  ended  successfully. 


INJURIES    OF    THE    NOSE 


225 


.  413. — Retention  apparatus  for  the  ncse.     It  is 
fixed  to  the  upper  teeth  by  a  metal  cap  splint. 


FIG.  414. — Result  obtained  by  operation  and  the 
wearing  of  the  apparatus  for  seven  weeks. 


FIGS.  4 15  and  410. — Result  of  plastic  opDrations  on  aloe,  and  cartilage  support  to  the  bridge.     Cartilage  was 
inserted  in  two  portions,  one  along  the  bridge  and  one  down  the  co'.uinella.     Date  of  operation,  9.3.11". 

15 


220 


PLASTIC    SURGERY 


CASE  36 


This  is  an  example  of  a  definite  group  of  nasal  injuries.  Those  cases  coming  to  one's 
attention  have  been  due  to  high-velocity  bullets  at  short  range,  traversing  the  face  ap- 
proximately from  one  malar  region  to  the  other.  Encountering  hard  bone  on  the  way, 
its  force  is  "transmitted  to  the  upper  jaw,  detaching  it  from  its  superior  attachment.  The 
whole  support  of  the  nose  is  also  destroyed,  and  replacement  of  what  remains  of  the  sup- 
porting structures  is  very  difficult,  unless  a  case  is  specially  treated  for  this  within  a  few 

davs  of  injury. 

The  complete  detachment  of  the  superior  maxilla  is  well  shown  in  the  photograph,  as 
is  the  condition  of  this  officer  on  arrival.  The  whole  face  is  lengthened,  and,  while  his  lower 
jaw  is  fully  open,  his  upper  teeth  are  in  contact  with  the  lower.  Ihere  is  some  evidence 
of  recession  of  the  upper  lip  owing  to  loss  and  displacement  of  the  underlying  bone.  In 
this  particular  instance  an  attempt  was  made  to  replace  the  nasal  bones  by  intra-nasal 
supports,  but  completely  failed.  1  he  treatment  of  the  fracture  of  the  upper  jaw  was  under- 
taken by  Captain  F.  E.  Sprawson,  R.A.M.C.,  with  Kingsley  type  splints,  and  the  excellent 
result  is  well  seen  in  the  shortening  of  the  face  (fig.  419).  Union  has  occurred  in  the  upper  jaw. 
Details.— The  sniper's  bullet  entered  by  the  right  malar  and  came  out,  after  fracturing 

the  maxillae,  through  the  left  cheek  at  the  side  of  the 
nose,  and  the  whole  of  the  nose  was  left  very  flat  and 
broad.  On  his  admission,  fourteen  days  after  injury, 
an  immediate  effort  was  made  at  replacement  by 
intra-nasal  splints,  but  without  appreciable  success, 
due  to  the  actual  loss  of  bone. 

Four  months  later  a  plastic  operation  was  per- 
formed to  raise  the  line  of  the  bridge  by  means  of 
perforated  shaped  celluloid.  The  diagram  of  this 
sufficiently  illustrates  the  manoeuvre.  It  was 
moderately  successful  in  appearance,  but  there  con- 
tinued to  be  some  slight  discharge  combined  with 
protrusion  of  the  celluloid  at  the  tip  of  the  nose,  and 
it  had  to  be  removed  after  two  months.  The  cellu- 
loid plate  was  J  in.  thick.  After  four  months,  during 
which  the  small  scar  at  the  tip  of  the  nose,  produced 
by  the  celluloid,  was  excised  under  local  anesthesia, 
the  patient  was  again  operated.  A  thick  piece  of 
rib  cartilage,  3  in.  in  length,  was  taken  from  the  right 
thorax  (8th) ;  this  was  grooved  on  its  under  surface 
so  as  to  obtain  greater  fixity  of  position.  From  a 
semi-lunar  incision,  with  its  convexity  downwards, 
at  the  root  of  the  nose,  the  skin  over  the  dorsum  of 
the  nose  was  freely  under-cut.  The  graft  was  inserted, 
and  its  upper  end  wedged  under  a  small  periosteal 

flap  of  the  frontal  bone.  In  order  to  give  more  prominence  at  the  middle  of  the  bridge,  a 
second  smaller  piece  of  cartilage  was  superimposed,  while  a  third  quite  small  piece,  through 
a  separate  incision,  was  used  to  reinforce  the  left  ala.  Slight  suppuration  followed  this 
operation,  and  lateral  incisions  were  made  about  half-way  down  the  nose.  This  infective 
discharge  continued  for  the  best  part  of  three  months,  i.e.  until  26.6.17.  Four  months 
later  the  condition  was  fairly  satisfactory  ;  the  main  graft  had  not  become  infected,  but  had 
somewhat  moved  its  position,  and,  covered  by  mucous  membrane,  was  plainly  palpable  at 
each  nasal  orifice.  There  is  deficiency  of  prominence  of  the  tip,  while  the  left  ala  has  not 
been  readjusted  since  the  wound.  Scars  were  also  present  from  the  previous  incisions. 

To  correct  these  deformities,  the  following  operation  was  carried  out.  A  sub-mucous 
resection  of  the  cartilage  graft  through  the  right  narcs  was  effective  in  increasing  the  size 
of  the  nasal  passage  and  in  providing  a  piece  of  cartilage.  This  incision  into  the  mucous 


Fio.  417. — Diagram  to  represent  the  im- 
plantation of  a  celluloid  support  to  bridge 
and  columella.  Result  :  failure. 


INJURIES    OF    THE    NOSE 


227 


Fio.  418. — Condition  on  admission.     Double  fracture  of  maxillae  with  downward  displacement. 

membrane  was  carefully  sewn  up  with  horsehair.  The  piece  of  cartilage  obtained  was 
roughly  an  inch  long.  It  was  shaped  and  inserted,  through  a  small  lateral  incision  in  the 
columella,  under  the  tip  of  the  nose  to  give  this  more  prominence.  Small  scars  were  removed, 
and  the  left  ala  was  lengthened  and  brought  more  central.  All  wounds  healed  by  first 
intention,  and  the  result  was  satisfactory.  This  is  probably  the  first  time  that  a  sub-mucous 
resection  of  imbedded  cartilage  has  been  carried  out  and  the  cartilage  reimbedded  in 
another  portion  of  the  nose. 

28.11.17. — Discharged  to  duty.     Result  very  satisfactory. 

1.4.18. — Returned  for  reconsideration.  No  further  plastic  is  at  present  advised. 
Still  requires  a  small  portion  on  the  tip  of  the  nose.  Although  the  nose  in  itself  is  fairly 
good  it  is  set  too  far  back  on  the  face,  owing  to  the  fracture  with  loss  of  the  superior  maxilla. 


FIG.  419. — Result  of  replacement  of  maxilla;  and  cartilage  implant  to  nose,  etc.     The  scars  on  tip  and 
lateral  aspects  of  nose  are  due  to  suppurative  troubles. 


•J-JS 


PLASTIC    SURGERY 


" 


CASE  252 

This  is  another  example  of  complete  upper  jaw  detachment,  with  destruction  of  the 
nasal  supports.  The  injury  was  due  to  a  bullet  at  short  range.  1  he  entry  and  exit  wounds 
are  visible  in  the  fig.  422.  The  terrible  deformity  is  best  realised  by  examination  of  fig.  4'20. 
which  portrays  his  condition  before  being  wounded.  The  whole  of  the  upper  part  of  the 
face  seemed  to  move  on  a  line  running  from  the  mid-part  of  the  glabellar  region  through 
the  orbit  above  the  bony  floor,  and  through  the  external  angular  process  to  the  temporo- 
mandibular  joint. 

The  treatment  given  this  case  was,  first  of  all,  an  attempt  to  manipulate  the  nose  and 
upper  jaw  into  position,  and  the  fitting  of  a  Kingsley  splint.  Two  months  later  it  was 
found  that  no  union  had  occurred,  and  a  stronger  type  Kingsley  was  applied. 

Serious  damage  had  been  done  to  this  patient's  vision,  which  became  worse  when  this 
stronger  splint  had  been  in  position  for  a  few  days.  T  he  splint  was  removed  and  the  eyes 
examined  by  Captain  Williams,  and  Mr.  Holmes  Spicer,  of  London.  An  exploratory 

operation  was  advised.  Captain  A.  Ryland,  K.A.M.C.. 
investigated  the  various  sinuses,  especially  the  sphenoi- 
dal.  Isio  pus  was  encountered,  but  after  a  severe  epis- 
taxis,  the  vision  gradually  improved  to  a  certain  extent. 
To  decrease  the  deformity  of  the  bridge,  a  combined 
bone  and  cartilage  graft  from  the  rib  was  inserted  from 
above  six  months  later.  The  diagrams  attached  show 
the  shape  of  the  graft  after  it  had  been  fashioned.  The 
bony  portion  was  split  and  fitted  over  the  freshened 
nasal  bones  like  a  penthouse,  while  the  attached  car- 
tilaginous rod  extended  down  to  the  tip  of  the  nose. 
A  very  marked  improvement  in  profile  occurred,  but  a 
twist  developed  in  the  car- 
tilage, which  marred  the 
effect.  This  operation  is 
described  because  it  is  an 
important  eilort  to  replace 
the  nasal  bridge  by  its  two 
elements,  bone  and  car- 
tilage. Bony  union  oc- 
curred between  the  rib  and 
nasal  bones.  A  piece  of 
cartilage  under  the  left  eye 
slipped  out  of  position.  No  further  treatment  has  been  undertaken  for  this  patient. 

After  consideration  of  later  cases,  there  is  no  doubt  that  this  case  should  have  been 
treated  on  the  lines  of  Case  155,  which  follows,  and  is  a  definite  failure  because  no  provision 
w.-is  made  for  the  large  amount  of  epithelial  lining  which  had  been  shot  away,  and  which 
had  necessarily  to  be  supplied  before  the  nose  could  be  restored  to  a  normal  position. 

These  three  cases,  36,  155,  and  252,  are  all  similar,  but  of  increasing  severity  of  loss. 
On  the  one  hand,  Case  36  was  successfully  treated  by  cartilage  implantation  alone,  while 
(  ;isr  155  had  a  considerable  new  amount  of  skin-lining  as  well  as  support  provided. ,  Case  252 
was  treated  on  the  lines  of  36,  but  should  have  been  treated  as  was  Case  155. 


Fia.  420. — Before  wound. 


FIG.  42 1. — Bone-cartilage  trans- 
plant from  rib.  The  bony  part 
is  split  and  is  shown  black  in  the 
diagram. 


INJURIES    OF    THE    NOSE 


229 


FIG.  422. — On  admission.     Note  downward 
displacement  of  maxillae. 


FIG.  423. — After  replacement  of  maxillae  by 
dental  splint. 


i* 


FIG.  424. — After  bone-cartilage  graft.     See  reading  matter  re  defects  in  designjand  technique  which 

produced  this  inferior  result. 


230  PLASTIC    SURGERY 

GROUP    IV 
LOSS    OF    THE    MIDDLE    PORTIONS    OF    THE    BRIDGE 

Having  discussed  the  transition  Case  252,  it  will  have  been  seen  that  the 
author  tried  to  treat  Case  155  at  first  on  the  lines  of  supplying  support  only. 
Fortunately  this  was  a  gross  failure. 

The  characters  of  this  group  are  that  there  is  complete  loss  of  the  bony 
and  cartilaginous  support,  together  with  serious  loss  of  the  lining  membrane. 
The  tip  becomes  drawn  up  and  back  until  the  nostrils  and  columella  are  so 
distorted  that  the  anterior  nares,  instead  of  looking  downwards,  look  directly 
forwards,  or  even  upwards.     "  Pug-nose  "  is  the  name  given  to  this  type  of 
deformity,  and  it  gives  the  unfortunate  possessors  a  most  repulsive  appearance. 
Treatment  on  the  lines  of  distending  the  skin  of  the  bridge  by  cartilaginous 
or  other  support  is  useless  because,  as  has  been  explained  before,  it  was  all- 
important  to  provide  the  necessary  skin  lining  in  addition.     It  occurred  to  the 
author  that  the  supporting  cartilage  might  be  previously  imbedded  in  the  flap  of 
skin  to  be  turned  down.     A  double  principle  .is  involved  in  this  procedure,  viz.  (1) 
provision  of  the  important  skin  lining  ;    and  (2)  the  imbedding  of  the  cartilage 
in  this  flap  rather  than  in  the  external  covering  flap.     Advantages  accrue  in 
that  the  necessary  length  of  cartilage  is  easily  gauged,  and  when  imbedded 
remains  in  its  position  ready  for  inversion  or  swinging  down.     Experience  has 
shown  that  a  cartilage  imbedded  in  the  forehead  often  moves  its  position  or  is 
bent  out  of  shape.     A  further  advantage  lies  in  the  fact  that  in  the  process 
of  hingeing  of  the  flap  of  skin  and  cartilage  there  is  a  distinct  tendency  for  the 
cartilage  to  spring  back.     This  naturally  has  the  effect  of  supporting  and  raising 
the  extremity  of  the  nose,  and  the  amount  of  spring  can  be  nicely  judged  while 
the  undercutting  of  this  skin-cartilage  flap  is  accomplished.     It  is  a  definite 
scientific   procedure,   capable   of  being   pre-judged.     The   name   given   to   this 
flap  is  the  "  Vallancey  swing,"  named  after  the  case  for  which  this  flap  was 
first  designed  and  used.      As    explained    in    the    chapter    on    Principles,   the 
author  lays  claim  to  this  "  swing  "  as  a  definite  new  principle  on  which  a  number 
of  plastic  procedures  are  based.     To  comply  with  the  tenets  of  this  principle 
the  supports  or  cartilage  must  be  previously  imbedded  in  the  flap  that  is  to  be 
inturned.     The  method  is  applicable  to  many  nose  operations  where  support 
and  lining  arc  required,  such  as  are  to  be  found  in  the  following  three  Groups  of 
cases,   IV,  V,  and  VI;    also   for  plastics   of  the  ala3,  of  the   eyelids,   for   ear 
restorations,  and  even  for  the  chin.     It  is  further  applicable  to  tracheal  repair 
and  other  plastic  procedures. 

Another  new  principle   of  a   minor  importance  was  evolved  in  this  case, 
and  that  is  the  creation  of  a  cartilage  store  in  the  subcutaneous  tissues. 


INJURIES    OF    THE    NOSE  231 

Sufficient  cartilage  for  the  whole  restoration,  with  a  spare  piece  for  accidents, 
is  taken  at  the  one  rib-operation,  and  the  spare  piece  is  inserted  under  the  skin 
of  the  upper  abdomen  or  thorax  for  future  use.  It  is  then  available  at  any 
time,  and  can  be  easily  reached  under  local  anaesthetic.  The  rib  operation  is 
a  distinctly  painful  one,  and  avoidance  of  a  second  is  a  great  advantage  to  the 
patient.  Moreover,  if  the  spare  cartilage  is  not  required  it  can  be  transferred 
to  another  patient,  saving  him  a  rib  operation. 


ILLUSTRATIVE    CASES 

The  typical  pug-nose  is  shown  in  the  following  case,  155.  Ihe  treatment 
of  this  condition  has  been  standardised  as  a  result  of  operative  procedures  in 
this  case. 

The  "  Vallancey  swing  "  consists  of  a  prior  imbedding  of  a  piece  of  cartilage 
of  the  necessary  length  in  the  middle  line  of  skin  remaining  over  the  glabella 
and  upper  nasal  region.  The  tip  containing  the  pug-nose  alas  is  definitely 
separated  from  the  upper  half,  and  the  gap  into  the  nose  between  the  two  kept 
open  until  the  second  stage  of  the  operation. 

The  cartilage,  having  been  successfully  imbedded,  is  raised  with  the  flap 
of  skin  over  it,  and  swung  directly  downwards,  its  lower  end  acting  as  the  hinge 
and  blood  supply. 

Ihe  skin  over  the  cartilage  thus  comes  to  line  the  nasal  cavity  where  that 
lining  is  missing,  and  the  end  of  the  cartilage  is  inserted  under  the  structures 
of  the  tip  of  the  nose  which  has  been  brought  down  to  a  normal  position  by 
cutting  its  attachment  deeply. 

The  rod  of  cartilage  thus  inserted  into  the  tissues  of  the  tip  effectively 
prevents  the  tip  from  being  pulled  backwards  and  upwards.  To  complete  the 
operation,  a  skin  covering  is  usually  provided  by  a  frontal  flap. 

This  radical  method  is  absolutely  effective  and  produces  uniformly  good 
results.  Great  care  must  be  taken  that  the  inverted  skin-cartilage  flap  has 
sufficient  blood  supply.  This  can  usually  be  secured  at  the  first  stage  of  the 
operation,  by  attaching  what  is  going  to  be  the  pedicle  of  the  inverted  flap  to 
the  mucosa  of  the  nasal  cavity.  It  occurs  sometimes  that  the  blood  supply  to 
this  flap  is  not  sufficient  to  permit  complete  incision  around  its  lateral  attach- 
ment ;  it  is  then  necessary  to  leave  a  pedicle  of  skin  from  one  or  other  side  of 
the  nose  to  be  divided  later. 

When  the  "  pug-nose  "  retraction  is  not  marked,  and  is  mainly  due  to  scar 
tissue,  it  is  not  always  necessary  to  insert  the  cartilage  ;  but  the  principle  re- 
mains the  same.  See  Cases  558  and  598, 


PLASTIC    SURGERY 


CASE  155 

Wounded  19. 9. 10. 

He  was  admitted  under  me  on  12.3.17.  A  mucoccele  of  the  left  lachrymal  sac  had 
been  operated  by  the  ophthalmic  specialist  at  the  Cambridge  Hospital,  Aldershot,  Capt. 
Williams,  R.A.M.C. 


FIGS.  425  and  426. — Condition  on  admission.     The  Pug-nose  deformity. 

At  this  time  the  author  was  giving  various  implanted  bodies  a  thorough  trial,  and  de- 
cided, in  consultation  with  one  of  his  colleagues,  to  insert  a  perforated  sheet-silver  bridge  of 


Flo.  427.— Diagram  of  a  paraffin-covered  silver  support  introduced  to  raise  the  bridge.     Failure. 


the  form  shown  in  the  diagram.     This  bridge  was  carefully  covered  with  sterilised  paraffin  wax 
ting  point,  and,  after  thorough  undercutting  of  the  skin,  was  imbedded  in  the 


INJURIES    OF    THE    NOSE 


233 


FIGS.  428  and  429. — Show  the  first  stage  of  the  author's  principle  of  nasal  reconstruction. 

tissues.  The  immediate  cosmetic  result  was  not  at  all  pleasing,  and,  in  addition,  the  chronic 
irritation  of  the  tissues  followed  by  suppuration  necessitated  its  removal. 

In  the  following  November,  some  six  months  later,  the  first  stage  of  restoration  was 
carried  out.  The  operation  notes  are  as  follows  : 

Stage  I. — Establishment  of  airway — cartilage  imbedded.      The  method  selected  was 


FIG.  430. — Illustrates  the  author's  principle  of  carrying 
spare  cartilage  subcutaneously  for  later  stages.  This 
saves  any  further  rib  operation. 


234 


PLASTIC    SURGERY 


FIG.  431. A  is  the  skin-cartilage  flap  which  is  swung  down  to  form  an  epithelial  lining  to  nose, 

a  support  to  the  bridge,  and  a  prop  to  prevent  the  retraction  of  the  tip  of  the  nose. 


FIGS.  432  and  433. — B  is  the  frontal  flap  to  form  the  external  covering.     The  lining  is  formed  by  the  skin  of  A 
now  inverted,  and  the  support  by  the  cartilage,  which  now  comes  to  lie  between  the  two  skin-layers. 

to  imbed  a  short  piece  of  cartilage  in  the  stump  of  the  nose,  and,  later,  to  turn  this  down 
skin  surface  inwards. 

This  piece  of  cartilage  was  taken  from  the  right  costal  region  and  imbedded  through 
a  small  incision  at  the  root  of  the  nose.  In  addition,  an  aperture  was  made  in  the  nose 
from  just  above  the  tip  and  the  edges  of  the  skin  tucked  in  towards  the  nasal  passage.  Ad- 
ditional cartilage  was  removed  and  imbedded  in  the  abdominal  wall  beneath  the  skin  for 
the  following  reasons : 

A.  As  an  extra  piece  for  the  nose. 

B.  As  a  cartilage  prosthesis  for  the  eye. 

C.  Spare  piece. 

All  wounds  healed  aseptically. 

Stage  //.—Flap  A  in  the  diagram,  fig.  431,  containing  cartilage,  was  swung  down,  leaving 
the  lower  portion  attached  for  deep  blood  supply.  The  tiny  pedicle  of  skin  was  also  left 
on  the  right  lateral  aspect  for  further  nourishment.  The  tip  of  the  nose  was  now  freely 
undercut  until  it  could  assume  a  normal  position  and  the  extremity  of  flap  A  was  sutured 
to  the  back  of  the  columella,  the  cartilage  being  fitted  into  the  tissues  of  the  tip. 


INJURIES    OF    THE    NOSE 


235 


Necessary  sutures  were  inserted  around  the  margin  of 
flap  A,  which  completely  closed  the  nasal  cavity  from 
the  operative  area,  except  for  its  tiny  pedicle  above 
mentioned.  A  model  of  the  raw  area  now  exposed  was 
made  in  tin-foil,  and  a  flap  of  the  exact  size  was  cut 
from  the  left  temporal  region  and  sutured  in  position.  A 
portion  of  the  tip  was  swung  down  to  give  a  little  more 
prominence,  and  a  corresponding  addition  to  the  frontal 
flap  made  to  cover  this  extra  raw  area.  A  skin-graft 
was  applied  to  the  extremity  of  the  raw  area  in  the 
forehead. 

Stage  III. — Return  of  pedicle  to  forehead,  and 
correction  of  eyebrow  levels.  The  fistula  resulting  from 
the  little  pedicle  to  flap  A.  stage  2,  was  excised.  Im- 
plantation of  cartilage  to  upper  part  of  bridge. 

The  satisfactory  result  produced  in  this  case  is  per- 
manent as  far  as  can  be  judged.  There  is  no  change 
except  for  the  better  (one  year  after  opeatiron). 


FIG.  434. — Sectional  view 
of  flaps  A  and  B,  with  the 
cartilage  lying  in  between. 


Fio.  435. — Profile  view  of  result.     Compare  with 
original  profile. 


FIG.  436. — Front  view.     Artificial  eye  inserted. 


230 


PLASTIC    SURGERY 


CASE  558. — Type  :  loss  of  the  middle  third  of  the  bridge  of  the  nose  and  of  the  semi- 
pug  variety. 

The  interesting  points  about  this  rhinoplasty  are  (1)  the  absence  of  cartilage  support ; 
(2)  the  method  of  re-making  the  left  ala  to  produce  symmetry  ;  and  (3)  the  question  whether 
it  would  not  have  been  better  to  have  made  the  frontal  flap  larger,  so  as  to  have  covered  all 
the  external  surface.  It  seems  to  the  author  that  it  should  have  been  brought  down  to  cover 
the  new  portion  of  the  left  ala,  as  at  this  spot  there  was  some  redness  of  the  skin — probably 
due  to  the  presence  of  mucous  membrane — otherwise,  compare  it  with  Case  598  (p.  240). 

Point  4. — When  the  pedicle  was  returned  to  the  forehead,  a  plastic  flap  of  the  scalp 
was  cut,  and  advanced  to  fill  in  the  gap.  As  this  man  has  weak  fair  hair,  the  advancement 
of  the  hair-line  is  of  no  disability.  A  further  point  of  interest  should  be  noted,  in  that  the 
usual  first  stage  of  such  an  operation  was  omitted,  \iz.  the  establishment  of  the  airway 
and  replacement  of  the  parts  in  their  normal  positions.  The  usual  first  stage  also  includes 
sewing  the  base  of  the  inturned  flap  to  the  mucous  membrane  to  ensure  its  blood  supply, 
and  in  this  case,  in  order  to  secure  the  blood  supply,  a  small  skin  pedicle  was  left  on  the 
right  side.  Subsequent  to  the  return  of  the  pedicle  a  large  collection  of  epithelial  debris 
had  to  be  evacuated  from  the  right  side  of  the  nose. 

A  bone-graft  from  the  tibia  had  been  inserted  into  the  bridge  of  the  nose  prior  to  the 
patient's  coming  into  the  author's  hands.  Various  other  plastics  had  apparently  been  done 
before  his  admission.  There  was  a  loss  of  the  inner  half  of  the  left  ala,  and  a  spicule  of  the 
bone-graft  was  discovered  on  top  of  the  nasal  bones. 

The  method  of  operation  consisted  of  excision  of  scar  tissue  and  freeing  the  tip  and  left 
ala,  until  their  normal  position  was  assumed.  The  skin  over  the  upper  part  of  the  bridge 
was  then  reflected  downward  on  its  deep  base.  As  the  blood  supply  was  insufficient,  a 
small  skin  pedicle  was  left  on  the  right  side.  When  this  flap  was  inverted,  it  was  sewn 
to  the  back  of  the  tip  and  alse.  In  order  to  complete  the  contour  of  the  left  ala  a  portion 
of  the  tip.  marked  Bl,  was  swung  to  the  left  and  sutured  to  the  remains  of  the  left  ala  (.B1). 
To  cover  the  raw  area  thus  produced,  a  forehead  flap  of  exact  size  was  taken  from  the  left 
frontal  region  and  sutured  into  position.  Union  was  satisfactory,  and,  despite  the  fact 
that  no  cartilage  was  in  the  inturned  flap,  there  was  no  tendency  for  the  tip  to  retract. 
The  pedicle  was  returned  two  months  later,  and  the  gap  in  the  forehead  was  repaired  by  a 


Tip  oF  nose  brought  down  and 
rwintamed  by  inverted  Hap  C. 
In  C  was  a  little  ostepfibrtus  tissue 
the  result  of  a  previous  tcbal  graft 


^<      ''NV 
</        V-."'  r)/ 


437.-B  is  the  frontal  flap  to  cover  the  defect.          Flo.  438.-The  gapjn  the  forehead  is  closed  by  the  return 

of  the  pedicle  and  by  a  "  V  Y  "  advancement  of  the  scalp. 


INJURIES    OF    THE    NOSE 


237 


FIGS.  439  and  440. — Pug-nose,  combined  with  ala  deficiency. 


FIGS.  441  and  442. — Soon  after  the  reconstruction.     (The  lymphatic  oedema  has  not  yet  subsided.) 


•k  V  Y  "  advancement  of  the  scalp.  Some  later  trouble  occurred,  due  to  the  tiny  pedicle 
of  the  inturned  flap  of  the  first  operation  ;  an  inclusion  epithelial  cyst  developed  on  the 
side  of  the  nose.  It  was  freely  excised,  and  no  further  trouble  has  arisen.  The  final  result 
is  shown  in  the  photographs.  The  eyelid  plastics  are  not  yet  complete. 


238 


PLASTIC    SURGERY 


(ASK  495. — The  disability  and  the  necessary  radical  nature  of  the  repair  were  originally 
much  under-estimated  in  this  case. 

It  was  first  thought  that  by  freeing  the  nose  on  its  right  aspect  one  should  be  able  to 
centralise  it  and  then  raise  it  by  cartilage  graft.  An  epithelial  graft  was  therefore  made 
to  free  the  adhesion  on  the  right,  and  an  apparatus  to  align  the  nose  was  worn  by  the  patient 
for  some  time.  It  certainly  straightened  the  nose  to  a  considerable  degree,  but  it  was  realised 


FIG.  443. — Pug-nose,  with  much  lateral  loss 
and  consequent  deviation  to  the  right. 


FIG.  444. — Profile  of  healed  condition. 


then  how  inadequate  the  procedure  was  ;    moreover,  a  severe  blockage  of  the  nasal  airway 
persisted. 

Therefore  this  first  idea  was  abandoned,  and  the  case  was  treated  on  the  usual  lines  of  the 
other  skin  cartilage  flaps.  A  flap  of  the  exact  size  was  cut  to  fit  the  raw  area  of  the  nose, 
and,  although  this  was  sufficient  for  the  nose,  no  allowance  was  made  for  loss  of  skin  of  the 
cheek ;  consequently,  there  is  still  a  slight  dragging  to  the  right,  although  the  whole  result 
is  a  very  satisfactory  one.  The  least  support  with  an  extra  piece  of  cartilage  would  have 
rectified  this  want  of  alignment,  but  the  patient  was  so  satisfied  that  he  did  not  wish  to  have 
anything  further  done. 

The  tip  has  been  brought  down  a  little  too  low,  but  could  have  been  further  raised  by 
the  implantation  of  a  columellar  rod  of  cartilage.  This  procedure  definitely  established 
a  good  airway  through  the  nasal  passages. 

The  pedicle  was  not  returned  to  the  forehead  as  the  scar-line  there  was  sufficiently 
satisfactory ;  hence  an  excision  and  rearrangement  in  the  glabellar  region  such  as  that  in- 
dicated. The  operation  details  are : 

12.4.18.  Operation. — Epithelial  outlay  inserted  under  right  aspect  of  nose  and  right 
ala  to  allow  this  to  swing  forward  into  position.  The  bridge  to  be  dealt  with  later.  The 
edges  of  the  skin  graft,  which  was  cut  very  thick,  were  included  in  the  sutures  which  kept 
the  stent  in  position. 

2 2. 7. 18.  —Epithelial  outlay  successful— deviated  nose  returned  to  normal  alignment. 

22.7.18.  Operation. — Preliminary  nasal  plastic.  Cartilage  from  eighth  right  rib — 
shaped  and  inserted  on  the  bridge  of  the  nose  through  incisions  between  eyebrows.  Tip 
of  nose  then  released  from  the  remainder  of  the  nose  :  skin  and  mucous  membrane  sewn 
together.  Nasal  passages  freely  opened,  and  airway  established.  The  remaining  unused 
cartilage  was  imbedded  under  the  skin  covering  the  chest. 

Result. — Satisfactory  healing.     Airway  established. 


INJURIES    OF    THE    NOSE 


239 


FIGS.  445  and  440. — First  stage,  showing  the  restoration  of  the  tip  to  normal  FIG.  447. — Diagram  of  second  stage  operation, 

position  and  tho  imbedding  of  cartilage  in  the  glabellar  region. 


FIG.  448. — Diagram  of  method  of  treatment 
of  the  pedicle  and  advancement  of  scalp.  No 
skin  graft. 


FIG.  449. — The  result. 


22.8.18.  Operation. — The  glabella  flap  A  was  swung  down  with  its  contained  cartilage, 
the  end  of  which  was  inserted  into  the  tissues  of  the  tip  to  hold  the  tip  down  and  straight. 
The  old  skin-graft  on  right  side  was  excised.  The  edges  of  flap  A  sewn  to  mucous  membrane 
to  complete  closure  of  nose.  A  flap  of  the  exact  size  was  cut  to  pattern  and  the  forehead 
sewn  up.  Result :  very  satisfactory. 

14.11.18. — Pedicle  partly  returned  and  partly  excised. 


'240 


PLASTIC    SURGERY 


CASE  508 

In  addition  to  a  major  loss  of  the  upper  lip  and  the  adjacent  portion  of  the  cheek,  this 
patient  suffered  destruction  of  all  the  lower  part  of  the  nose  save  the  columella  and  left  ala. 
Some  beautifully  drawn  diagrams  by  Lieut.  D.  E.  Lindsay,  attached  A.A.M.C.,  graphically 
describe  the  methods  of  repair. 

The  columella  had  to  be  freed  and  resutured  in  its, back  surface,  so  as  to  have  no  ten- 


/Ik 


FIGS.  450  and  451. — Loss  of  the  lower  part  of  the  bridge  and  right  ala.     Lip  deformity. 

dency  to  retract  upwards,  and  a  complete  new  right  ala  had  to  be  made  in  addition  to  the 
top  of  the  nose.  For  some  reason — which  is  not  recalled — no  rod  of  cartilage  was  implanted 
prior  to  the  restoration,  and  the  flap  of  skin  from  the  upper  remaining  portion  of  the  bridge 
was  swung  down  and  sutured  to  the  back  of  the  tip  and  left  ala.  The  lining  of  the  right  ala 
was  made  by  dissecting  out  a  lateral  flap  from  the  large  deep  depression  over  the  right 
antrum.  This  was  turned  skin  inwards  and  sutured  along  the  lower  border  of  the  first 
flap.  A  right  frontal  flap  of  exact  size  and  shape  was  brought  down  over  this  raw  area. 
Xo  attempt  was  made  to  repair  the  cheek  and  lip  deformity.  It  is  proposed  to  insert  some 
cartilage  between  the  two  flaps  to  give  the  lower  part  of  the  nose  a  more  definite  shape. 
A  very  excellent  line  of  union  has  been  obtained  between  the  old  and  new  parts  of  the  nose, 
so  that  in  certain  areas  the  line  is  indistinguishable.  An  excellent  forehead  scar  was  also 
produced,  and  instead  of  replacing  the  pedicle  it  was  excised  and  the  eyebrows  rearranged. 
The  right  eyebrow  is  still  slightly  higher  than  the  left ;  but  this  is  more  than  counter-balanced 
by  this  small  frontal  scar.  The  upper  lip  and  cheek  repair  is  a  specially  shaped  flap,  which 
was  considered  suitable  for  this  case.  Operation  details  are  given  below  : 

22.6.18.  Operation. — An  incision  made  over  the  skin  of  the  upper  portion  of  the 
nose,  as  marked  on  diagram,  which  enabled  flap  A  to  be  reflected  skin  inwards.  At  the 
same  time,  this  incision  freed  the  remains  of  the  columella  and  left  ala  so  that  they  could 
be  brought  into  normal  position. 

The  extremity  of  flap  A  was  sewn  behind  the  columella.     Flap  B,  which  was  a  natural 


INJURIES    OF   THE    NOSE 


241 


flap  lying  inside  scar  lines,  was  reflected  inwards  to  line  the  right  ala,  and  sutured  to  the 
under  surface  of  the  tip  and  along  its  upper  border  to  flap  A.  The  reflection  of  flap  B  was 
carried  right  up  to  the  nasal  aperture,  so  that  there  was  a  good  curl  for  the  new  ala.  A 
suitable  flap,  cut  to  the  exact  size  of  the  nose,  was  turned  down  from  the  right  frontal  region. 


Fio.  453. — Lettering  has  been  omitted  on  diagrams 
Flap  A  is  the  upper,  and  flap  B  the  lower,  of  the  two 
flaps.  Both  are  shown  after  their  inversion  and  suture 
to  the  back  of  columella. 


Fid.  452. — Diagram  of  healed  condition. 

No  attempt  was  made  to  extend  this  flap  to  take  any  part  in  the  repair  of  the  cheek.  In 
regard  to  the  cheek,  the  deeply  depressed  scar  was  excised,  and,  as  a  preliminary,  a  fat- 
flap  was  turned  in  underneath  it  and  the  tissue  of  the  cheek  advanced  to  meet  the  upper 
lip.  No  attempt  made  at  this  operation  to  correct  ectropion  of  upper  lip.  Progress  very 
satisfactory. 


FIG.  454. — Raw  areas  after  excision  of  scar 
and  inturning  flaps  to  line  nose. 


Fio.  455. — Shape  of  the  frontal  flap  and  its  suture  as 
the  external  covering  of  the  new  portions  of  nose. 


16 


•_'  H' 


PLASTIC    SURGERY 


15.8.18.   Operation. — Treatment  of  nose  pedicle. 

(1)  Partial  excision  of  redundant  skin.     No  replacement,   as  the  eyebrow  was  only 
slightly  raised  and  the  forehead  scar  was  very  good. 

(2)  Excision  of  scar  tissue  above  right  corner  of  mouth.     The  remaining  portions  of 


\ 


FIG.  456. — The  lip  incision. 


Fio.  457. — The  lip  suture. 


the  upper  lip  hereabouts  were  freed  as  two  small  flaps,  and  sewn  together  in  correct  position 
to  complete  vermilion  border.  To  fill  the  large  gap  caused  by  this  rectification  and  the 
excision  of  the  scar,  a  new  flap  was  designed  (original) — model  is  attached — and  sewn  into 
position  with  catgut  and  horsehair.  It  fitted  very  snugly  into  position,  owing  (1)  to  being 
cut  on  the  curve ;  (2)  the  extra  excision  of  some  indifferent  skin  to  allow  the  pedicle  to 
twist  easily.  Secondary  closure  difficult  but  satisfactory.  Retention  sutures  used. 


Fio.  4»«.— Hap  to  reconstruct  upper  lip  and  cheek          FIG.  459.-Suture.     This  diagram  also  shows  method 
nasal  reconstruction.  of  deaUng  with  the  nose  pedicle  by  excision  as  compared 

with  replacement. 


INJURIES    OF    THE    NOSE 


243 


FIG.  460. — Frontal  flap  in  position. 


FIG.  461. — Pedicle  returned  and  lip  repaired. 


FIG.  4C2. — Same  full  face.     Note  the  slight 
elevation  of  the  right  eyebrow. 


L'U 


PLASTIC  SURGERY 


CASE  C27 

After  examination  of  the  first  record,  one  is  inclined  to  regard  this  case  as  a  minor 
injury.  In  fact,  it  was  not  thought  that  it  would  be  necessary  to  do  more  than  an  excision  of 
scar  combined  with  a  small  cosmetic  implantation  of  cartilage.  This  was  an  error  of  diag- 
nosis, in  that  one  had  not  appreciated  the  amount  of  loss  that  had  already  occurred,  and  what 
was  going  to  occur,  in  the  middle  structures  of  the  nose.  The  left  antrum  was  involved  and 
most  of  the  bony  supports  on  the  left  side  underwent  necrosis.  Unfortunately,  a  photograph 
was  not  taken  of  the  stage  immediately  prior  to  operation,  but  an  excellent  plaster  cast. 
by  Lieutenant  J.  W.  Edwards,  Sculptor  to  the  Department,  has  preserved  a  record  of  this 
stage.  Comparing  this  with  the  photo,  it  will  be  seen  what  a  large  deformity  had  super- 
vened. A  very  small  "  Vallancey  swing"  was  used,  and  the  frontal  flap  was  carried  on  a 
long  tube-pedicle,  containing  a  branch  of  the  superficial  temporal  artery.  A  most  excellent 
repair  was  effected,  with  invisible  scars.  A  part  of  the  tube  was  subsequently  imbedded 
in  the  cheek  beneath  the  left  eye  to  fill  up  an  existing  hollow,  and  the  rest  of  the  pedicle 
was  returned  to  the  scalp.  It  should  be  observed  with  these  long  pedicles,  having  a  large 
arterial  supply,  that  a  sufficient  venous  return  is  provided  ;  otherwise  thrombosis  is  liable 
to  occur  at  the  extremity  of  the  flap.  No  fear  of  this  occurred  in  this  instance,  as  the  pedicle 
was  cut  sufficiently  wide.  The  great  advantage  of  this  method  of  bringing  down  the  neces- 
sary skin  is  that  it  leaves  the  lower  part  of  the  forehead  untouched  by  scars,  and  the  scar 
remaining  is  one  running  parallel  to  the  natural  lines.  The  operation  notes  of  this  case 
follow : 

16.7.18.  Operation. — Cartilage  from  rib  removed  and  inserted  over  bony  bridge  of 
nose,  and  spare  cartilage  imbedded  in  abdominal  wall  subcutaneously.  Scar  tissue  now 
freely  excised.  Lower  part  of  nose  freed  and  by  careful  suture  of  skin  and  mucous  membrane 
retained  in  its  normal  position.  Similarly,  skin  was  sewn  to  mucous  membrane  in  upper 
margin  of  the  central  nasal  aperture  and  airway  established.  Result  satisfactory. 


Fid.  403.— Cast  on  which  the  flaps  were 
designed.  The  lining  and  support  were 
made  by  inverted  flaps,  that  over  the 
bridge  ,,„, laming  a  rod  of  cartilage 
The  supoHic-ial  temporal  flap  is  outlined 


^^•^^^^^•^•••^•^^^^•^••^•^^•••^••^^^B 

FIGS.  464  and  465. — Condition  when  suppuration  has  ceased  and  skin  edges 
have  been  united  to  mucous  membrane  around  the  aperture. 


FIG.  466. — Cast  of  the  suture.     Note  Fio.  467. — Diagram  of  the  reconstruction.       Fio.  468. — Shows  the  tube-pedicle  lying 

the  tubing  of  the  temporal  flap.  on  the  cheek. 


FIG.  469.— Result  after  return  of  pedicle.  Fia.  470. — Side  view.  Note  that  part  of  the  pedicle 

has  been  imbedded  in  the  cheek  to  raise  the  eye.  (This 
has  been  smoothed  out  by  subsequent  operation,  in- 
cluding a  small  cartilage  transplant  from  the  left  ear,) 

14,10.18.  Operation.— I.  Small  flap  with  its  contained  cartilage  over  bridge  of  nose 
cut,  undercut,  and  swung  down,  skin  surface  inwards,  and  sutured  to  back  of  tip,  extremity 
of  cartilage  extending  into  the  tip.  The  upper  edge  of  the  tip  had  to  be  freely  excised  in 
order  to  arrive  at  healthy  skin. 

2.  Instead  of  carrying  this  flap  on  the  usual  pedicle  it  was  carried  by  a  pedicle  along 
the  left  temporal  artery.  When  sutured  into  position  the  pedicle  lay  across  the  cheek 
beneath  the  left  eye  (see  photograph).  Pedicle  tubed  and  flap  sutured  into  position.  Fore- 
head closed  by  approximation.  The  upper  part  of  the  bridge  from  which  the  small  flap 
had  been  taken  was  covered  in  by  approximation  over  the  bridge.  Result  very  satisfactory. 

Stage  ///.—Part  pedicle  returned  to  scalp.     Part  imbedded  in  cheek— local  anaesthesia. 


PLASTIC   SURGERY 


GROUP    V 

LOSSES    OF    THE    ALA    AND    LOWER    THIRD 

The  seven  cases  under  this  group  vary  from  a  very  minor  injury  to  the  tip 
and  ala  to  the  major  loss  of  the  lower  third  of  the  nose.  Intermediate  between 
these  two  extremes  lies  the  type  known  as  the  Indian  Mutilation.  The  more 
severe  cases  border  on  the  next,  or  Group  VI,  in  which  is  described  loss  of  the 
lower  two-thirds. 

CASE  730 

This  Case  is  chosen  for  illustration  for  several  reasons.  In  the  first  place,  it  is  an  ex- 
ceedingly minor  injury,  the  design  for  the  repair  of  which  gave  the  author  considerable 
concern.  The  rest  of  the  face  is  absolutely  untouched,  and  one  hesitated  to  make  a  scar 
anywhere.  How  was.  one  to  provide  the  skin  covering  and  lining  ?  After  considering  the 
various  possibilities,  such  as  the  tubed  temporal  region  flap,  and  a  flap  from  his  arm  or  neck, 
it  was  decided  to  attempt  a  whole-thickness  free-graft.  On  the  forehead,  these  whole-thick- 
ness grafts  are  almost  uniformly  successful,  but  in  that  site  the  immobility  of  the  surrounding 
parts  and  the  excellent  blood  supply  probably  determine  their  success,  whereas  newly 
swung  inturned  flaps  were  not  considered  a  very  hopeful  bed.  As  will  be  seen,  the  graft 


Fio.  471. — Shows  inversion  of  small  skin  flaps  in 
neighbourhood  of  defect  to  complete  lining  and  support 
for  graft. 


Fio.  472. — The  graft  sewn  into  position. 


was  successful,  and  a  symmetrical  tip  was  produced.  There  is,  however,  no  prominence 
to  it  as  no  supporting  tissue  could  be  utilised.  It  is  possible,  however,  that  after  an  interval, 
say  of  a  year,  cartilage  of  satisfactory  size  could  be  imbedded.  Following  are  details  of 
the  repair  : 


INJURIES    OF    THE    NOSE 


247 


FIGS.  473  and  474.— Show  the  effect  of  thu  injury.     There  is  loss  of  part  of  the  tip  and  right  ala. 


FIGS.  475*and  476. —  Result  of  Wolfe  graft. 


17.12.18.  Operation. — Attempt  to  make  a  whole-thickness  skin-graft  instead  of  flap. 
To  form  lining  of  right  ala,  a  flap  from  the  left  was  swung  across  and  stitched  to  the  skin 
of  the  vestibule  on  right  side.  Scar  tissue  excised  and  raw  area  made,  symmetrical.  A 
whole-thickness  graft  cut  from  the  arm  was  stitched  into  place.  Graft  took  in  its  entirety. 


248 


PLASTIC    SURGERY 


CASE  258 

An  even  smaller  loss  of  the  tip  than  the  first  illustration  in  this  group.  This  loss  was 
treated  by  simple  swinging  advancements  of  a  whole  thickness  variety — that  is  to  say, 
the  flap  made  consisted  of  skin,  cartilage,  and  mucosa. 

This  gave  a  fairly  satisfactory  result,  but  is  obviously  a  compromise,  and  hardly  a 
reconstruction.  An  attempt  to  swing  the  right  ala  further  forwards  and  down  resulted 
in  suppuration,  which  marred  the  effect.  The  case  was  an  early  one. 


Fio.  477. — Incisions  for  advancing  flaps. 

Details  of  operation  are  appended. 
Partn™;6;^01*"1*1011  fuF  reformation  of  tiP  °f  nose.     A  thick  flap  containing  skin 

"ted t ™TnCOUfS  Tm  nanC  T5,  CUt  according  to  diagram,  and  brought  down  and 
to  remains  of  columella  and  ales  to  form  new  tip 

spoilt Vhl' res'ul?^1'0"'"11116  "ght  ^  W&$  lndsed  &nd  br°Ught  forward'     Suppuration 
right*'?  ;*  ^  *°  ^  ^^  ^  ^^  °f 


INJURIES    OF    THE    NOSE 


249 


Fid.  478. — Partial  loss  of  the  tip. 


Fio.  479. — Result  of  treatment. 


250 


PLASTIC    SURGERY 


CASE  381 

An  atypical  deformity  of  the  tip  and  left  ala.  The  interest  of  this  case  centres  in  the 
use  of  a  caterpillar  flap  in  which  a  good  section  of  tissue  is  made  to  advance  in  two  stages 
on  its  own  pedicles.  First  of  all,  the  lower  end  is  used  as  a  base,  and  the  upper  end  is  ad- 
vanced towards  the  lower.  A  hump  is  thereby  produced  in  the  middle  of  the  flap.  W  hen 
the  upper  part,  thus  moved,  has  an  attachment  and  a  blood  supply,  the  lower  part  is  raised 
and  the  hump  straightened  out. 

Never  having  executed  this  manoeuvre  before,  one  was  fearful  of  difficulties  of  blood 
supply,  especially  in  the  second  stage.  However,  the  first  stage  proved  to  be  the  more 
dangerous,  while  the  second  stage  gave  me  no  cause  for  alarm. 

27.11.17.  Operation. — A  blob  of  nasal  tissue  was  lying  in  the  middle,  which  would 
make  a  useful  tip  if  it  could  be  shifted  down  into  position.  An  attempt  to  do  this  was 
made  in  the  following  manner  : 

The  skin  from  the  dorsum  of  the  nose  was  incised  so  as  to  allow  it  to  shift  down  cater- 
pillar fashion  as  a  first  stage.  It  is  hoped  that  in  the  second  stage,  when  the  caterpillar  is 
straightened  out,  the  fleshy  lump  above  referred  to  can  be  raised  and  brought  into  position 
for  the  new  tip.  The  blood  supply  of  this  flap  was  not  at  all  satisfactory,  and  it  had  to  be 
loosely  sewn  together  afterwards.  It  is  doubtful  whether  the  blood  supply  to  the  flap 
from  the  new  position  will  be  sufficient  when  the  lower  mass  is  detached.  The  diagrams 
represent  the  first  stage  of  the  caterpillar  movement. 

26.2.18.  Operation. — The  blob  above  referred  to  was  detached  from  below  and  the 
back  of  the  caterpillar  straightened  out.  Great  care  was  exercised  in  separating  the  two 
halves  of  the  middle  hump.  The  blood  supply  of  the  flap  appeared  quite  satisfactory,  and 
the  flap  made  a  very  satisfactory  tip.  It  was  not  quite  broad  enough  to  fill  up  the  gap  on 
left  side,  and,  as  it  was  not  deemed  advisable  to  put  it  on  tension,  this  gap  was  filled  by  a 
whole  thickness  of  skin-graft  from  the  lobule  of  the  right  ear.  Adjustment  of  the  remains 
of  the  columella  and  new  tip  were  made. 

Progress. — The  free  graft  did  not  take  ;  otherwise  satisfactory. 

2.7.18.  Operation. — Redundant  portion  of  columella  excised,  and  portion  of  the  new 
tip  swung  to  left  to  complete  new  ala.  Result  satisfactory. 

24.7.18. — Excision  of  small  scar  left  side  of  nose  under  2  per  cent,  novocaine. 

3.9.18. — Discharged  to  duty. 

?  further  treatment  any  advantage. 


i 
n 
in 


-TL 


FIG  480. — Incision  for  first  stage. 


FIG.  481. — Suture  of  the  first  and  second 
Below,  the  caterpillar  principle. 


INJURIES    OF    THE    NOSE 


251 


FIGS.  482  and  483. — Condition  on  admission. 


FIG.  484. — First  stage  of  caterpillar  movement. 


FIGS.  485  and  486. — Besult  of  this  advancement.     Note  the  defect  of  the  left  ala. 


L'.VJ 


PLASTIC    SURGERY 


CASE  70 

The  following  case  is  shown  as  an  example  of  a  compromise.  The  large  columella 
is  detached  from  below  and  converted  into  the  left  ala,  which  is  missing.  This  manoeuvre 
gives  a  fairly  satisfactory  appearance  by  very  easy  means.  The  absence  of  the  columella 
is  a  distinct  disadvantage.  In  this  particular  patient  the  rest  of  the  wound  was  so  large 
and  important  that  an  operation  which  would  quickly  obtain  a  result  was  indicated.  The 
case  is  illustrated  because  this  particular  manner  of  making  an  ala  may  be  found  useful 
in  other  cases.  The  details  of  the  case  and  the  diagrams  of  the  cheek  operations  are  included 
here. 


Fio.  487. — Detaching  columella. 


FIG.  488. — To  make  ala. 


28 . 11 . 16 .  Operation. — Removal  of  sequestrum. 

Condition. —Large  loss  of  cheek  and  left  ala  of  nose. 

METHOD  OF  TREATMENT.— 1.  Lateral  sliding  and  ascending  cheek  flaps.  Successful. 
2.  Local  fat-flaps  under  depressed  scar.  Satisfactory.  3.  Formation  of  left  ala,  by 
utilising  columella.  A  satisfactory  makeshift. 

PLASTIC  OPERATION.— 27.9.16.— Plastic  operation  on  face. 

PLASTIC  OPERATION.— 27.11.16.— Second  plastic  operation.  Excision  of  scar  on  the 
t  cheek  and  occlusion  of  the  gap  with  local  fat-slide,  left  ala  of  nose  freed  and  brought 
down  three-quarters  of  an  inch  in  the  middle  line. 

PLASTIC  OPERATION.— 12.1.17.— To  reinforce  left  ala.  The  columella  dissected  up 
>m  lip  and  short  flap  made.  Existing  ala  freshened  and  undercut,  and  columella 
turned  upon  itself  and  sutured  along  line  of  ala.  The  split  base  of  columella  sutured 
to  form  a  new  one. 


INJURIES    OF    THE    NOSE 


253 


Fra.  489. — Condition  on  admission. 


FIG.  490. — After  cheek  plastic. 


Fio.  491. — Profile  view  of  new  ala. 


FIG.  492. — View  from   below,  showing    deficiency 
of  columella. 


254  PLASTIC    SURGERY 

CASE  10 

This  case,  although  an  incomplete  one,  is  shown  for  various  special  reasons. 

In  the  first  place,  it  is  one  of  two  examples  of  a  star-shell  burn  in  our  clinic,  and  re- 
presents the  effect  of  a  magnesium  flare  fired  from  a  Verey  Light  pistol  at  close  range.  It 
is  the  more  deplorable  because  of  the  foolish  nature  of  the  accident.  The  effect  would 
appear  to  be  due  to  two  causes,  one — the  force  with  which  the  projectile  penetrated  the 
face,  and  the  other — the  burning  effect  of  the  magnesium  on  the  inside  of  the  maxilla. 
Practically  the  whole  of  the  interior  of  the  nose  was  burned  away. 

The  floor  of  the  nose,  the  septum,  the  left  lateral  nasal  wall,  the  left  alveolar  process, 
and  the  floor  of  the  left  antrum  were  found  involved  in  the  destruction.  Excessively  thick, 
non-yielding  scar  tissue  bound  the  upper  to  the  lower  jaw  on  the  left  side.  The  skin  lesion  is 
apparent  in  the  photograph,  figure  493,  and  includes  a  portion  of  the  upper  lip,  cheek,  left 
ala,  and  a  portion  of  the  nose. 

This  case,  the  only  one  the  author  has  treated  by  the  Tagliacotian  method,  was  un- 
finished owing  to  the  death  of  the  patient  from  a  severe  concurrent  disease,  and  the  record 
of  the  case  is  not  as  complete  as  the  actual  result.  The  method  of  forming  the  ala  is  of 
considerable  interest ;  a  piece  of  cartilage  was  taken  from  the  antihelix  of  the  left  ear  and 
inserted  in  the  left  arm  with  the  skin  tucked  underneath  it  to  form  an  ala.  This  was  trans- 
ferred to  the  nose  after  suitable  interval,  the  arm  being  held  in  place  by  plaster  bandages. 

However,  considerable  suppuration  of  the  flap  occurred  during  this  stage,  which  may 
have  been  caused  by  frequent  contamination  with  vomitus.  Nevertheless,  it  was  success- 
fully grafted  over  the  cavity  in  the  face,  and  the  new  ala,  although  not  in  position,  was 
obviously  a  satisfactory  one.  A  subsequent  minor  operation  resulted  in  its  being  dove- 
tailed and  modelled  into  the  nose,  giving  a  still  better  appearance  with  a  great  promise 
of  an  {esthetic  result.  On  the  third  day  following  this  operation  a  very  severe  attack  of 
erysipelas  occurred,  followed  by  a  small  amount  of  local  gangrene  and  septic  broncho- 
pneumonia,  from  which  the  patient  died  in  isolation  hospital. 

There  is  no  doubt  that  more  time  should  have  been  allowed  to  elapse  between  operations, 
but  at  that  time  conditions  were  such  that  it  was  rather  important  to  proceed  as  quickly 
as  possible  with  cases,  one's  judgment  notwithstanding. 


Fid.  493  -Effect  of  Verey  Light  injury.     Note  small  hole  externally,  with  extensive  destruction  of  the,  maxilla. 


INJURIES    OF    THE    NOSE 


255 


Fio.  494. — The  new  ala  formed  on  the  arm  by  tucking  skin 
round  a  piece  of  ear  cartilage. 


Fio.  495. — Transference  to  nose. 


Fio.  496. — The  good  shape  of  the  new  ala  is  seen.     lt_was  subsequently  brought  into  a  more  central  position.     See  text. 


25C 


PLASTIC    SURGERY 


CASE  452 

This  is  a  case  of  a  R.A.M.C.  (Field  Ambulance)  orderly  who  lost  the  tip  of  his  nose  by 
a  piece  of  shell.  The  loss  is  minor  compared  with  the  other  cases,  and  the  treatment  meted 
out  seems  radical. 

The  results,  however,  in  the  author's  opinion,  justify  the  procedure,  and  give  a  more 
satisfactory  appearance  than  any  cheek-flap  would  have  done — i.e.  the  French  method. 
There  are  one  or  two  examples  of  tip,  alas,  and  columella  being  made  by  French  method 
showing  excellent  results,  notably,  a  case  of  my  colleague,  E.  Seccombe  Hett,  F.R.C.S. 

\Vhere  the  loss  is  one-sided  and  very  small  I  think  this  is  probably  a  better  operation 
than  the  Indian  method,  but  where  the  loss  is  both-sided  the  frontal  flap  method  appears 
to  give  the  best  results. 

Details  are  appended : 

21.2.18.  Operation. — Rhinoplasty,  tip  and  part  alae  of  nose. 

Method. — Indian,  plus  inverted  skin-flap. 

Inverted  skin-flap  A  outlined  from  dorsum  of  existing  nose  sewn  B  to  B'  and  C  to  C'. 

In  reflecting  flap  A,  a  little  bit  of  cartilage  was  taken  from  the  septum  so  as  to  give 
stiffening  to  the  tip  and  columella.  The  raw  area  thus  made,  represented  in  diagram  2, 
was  covered  by  a  shaped  flap  taken  from  the  right  of  the  forehead  and  swung  into  place. 
This  was  cut  the  exact  shape  of  the  raw  area  as  measured  by  tin-foil.  The  pedicle  was  very 
long  and  very  narrow.  Bridge  flap  variety.  Sutured  into  place. 

Satisfactory  appearance.     The  raw  area  in  the  forehead  was  almost  completely  closed. 


BB'  cc'  BB' 


Fio.  497.— Flap  A  is  the  inturned  flap,  of  which  the  points  S  and  C  are  sutured  at  B'  C'. 

Progress—  Satisfactory,  except  slight  haemorrhage  from  bridge  portion  of  pedicle. 
; ^?;7*!;?ntal  flaP  cut  thin'  including  only  part  of  Frontalis  muscle. 
6.3.18.   Operation.— Return  of  pedicle.     Osteotomy  nasal  bones. 
Result. — Satisfactory. 

25.C.18.   Operation.— To  rectify  columella,  which  showed  a  perforation  or  window  on 
1  view      Local  anaesthetic.      A  small  flap  on  each  side  was  brought  forward  from 
the  remains  of  the  septum  and  sutured  to  the  existing  columella 
Result. — Satisfactory. 


INJURIES    OF    THE    NOSE 


257 


FIGS.  498  and  499. — Indian  mutilation  type.     The  healed  condition. 


Fio.  500. — Shows  the  frontal  flap  with  its 
pedicle  lying  over  the  glabella. 


17 


FIGS.  501,  502,  and  503. — Result  after  return  of  pedicle. 


258  PLASTIC'    SURGERY 

INJURY  OF  THE  LOWER  THIRD  OF  THE  NOSE  TREATED  BY  A  METHOD 

OF  THE  AUTHOR'S 

Four  cases  of  injury  of  the  lower  third  of  the  nose  have  been  treated  on  a 
new  principle.  Case  145  which  has  just  to  be  described  was  a  failure,  but  the 
other  three  have  all  been  very  useful  restorations.  The  principle  of  the  opera- 
tion is  exceedingly  difficult  to  explain.  It  is  suitable  only  for  losses  of  the 
lower  third  involving  tip  and  one  ala.  It  is  not  suitable  if  the  other  ala  has 
been  destroyed.  First,  the  distance  from  the  existing  nasal  bridge  to  the  ideal 
tip  is  measured  and  a  piece  of  cartilage  of  that  length  and  of  proper  diameter 
taken.  Commencing  half-way  up  the  forehead  in  the  middle  line,  an  incision 
is  carried  down  through  the  skin  on  the  less  damaged  side  of  the  nose,  which 
incision  is  stopped  at  the  lower  border  of  the  nasal  bones.  A  similar  incision 
is  made  on  the  opposite  side  starting  from  the  same  point,  and  this  V-shaped 
flap  reflected.  Underneath  this  is  inserted  the  piece  of  cartilage,  which  is  pushed 
down  to  the  base  of  this  flap.  The  flap  is  swung  back  into  position  and  the 
first  stage  is  complete.  The  second  stage,  after  three  or  four  weeks,  consists 
of  the  raising  of  the  same  flap  through  the  same  incision,  but  in  the  flap  is  included 
the  previously  imbedded  cartilage.  The  incision  on  the  sound  side  is  now 
deepened,  and  as  the  knife  leaves  the  border  of  the  bony  bridge  it  is  carried 
through  all  thicknesses  into  the  nasal  cavity  and  continued  down  close  to  the 
septum.  On  the  side  of  the  loss,  the  incision  is  carried  down,  gradually  getting 
wider  until  it  extends  outwards  and  downwards  into  the  check.  By  carrying 
the  knife  beneath  the  cartilage,  it  is  undercut  until  the  lower  border  of  the  bony 
bridge  is  reached.  Here  it  is  turned  directly  downwards  into  the  nose,  and  all 
tissues  are  cut  through,  including  the  septum.  The  whole  flap  now  consists  of  the 
remains  of  the  columella,  the  affected  ala,  the  long  skin-flap,  and  the  cartilage, 
together  with  a  small  portion  of  the  anterior  part  of  the  septum.  Its  blood 
supply  comes  through  the  columella  and  septum,  and  through  the  lateral  pedicle 
on  the  affected  side.  It  is  freely  movable,  and  the  lower  extremity  of  the 
imbedded  cartilage,  with  the  skin  over  it,  is  made  in  the  position  of  the  new  tip. 
The  upper  end  of  the  cartilage  now  slips  off  the  bony  bridge  and  is  abutted  on 
its  lower  aspect.  Similarly,  the  mutilated  ala  comes  to  lie  in  a  position  of  a  true 
ala,  skin  suture  is  effected  in  this  new  position  while  the  sound  ala  is  sutured 
to  the  new  tip. 

In  reviewing  this  method  it  is  obvious  that  there  is  a  certain  amount  of  raw 
area  beneath  the  cartilage  at  its  upper  end  and  beneath  the  flap  just  above 
the  new  ala.  More  by  luck  than  by  judgment,  the  cartilage  has  not  become 
infected  nor  is  the  new  ala  seriously  contracted  in  my  cases,  and  the  raw  areas 
have  Ix-romr  epithelialised.  It  is  quite  feasible,  should  one  be  doing  this  opera- 
tion again,  to  provide  the  necessary  lining  for  these  raw  areas. 


INJURIES    OF    THE    NOSE 


259 


CASE  111 

This  was  the  second  case  of  total  rhinoplasty  attempted.  This  terrible  injury  in- 
volved destruction  of  the  entire  nose,  the  middle  half  of  the  upper  lip,  the  pre-maxilla, 
and  the  lateral  nasal  processes  of  the  superior  maxilla.  There  was  also  considerable  loss 
of  the  soft  tissue  of  the  cheeks. 

When  he  had  sufficiently  recovered  from  his  wound,  the  upper  lip  was  remade  by  descend- 


A.  Periosteum. 
B  .   Rib  cartilage. 
C  .   Skin  flap.. 

The   periosteum    wa,s  put  round    the   cartilo-ge 
and    wa.s   sutured    below. 

Fia.  505. — View  of  the  forehead  from  above. 


Fio.  504. — The  healed  condition  after  the  palate 
remains  had  been  returned  by  dental  appliance. 

ing  lateral  flaps,  the  mucous  membrane  being  advanced  to  complete  the  red  border.  This 
was  moderately  successful,  but  there  was  an  ugly  droop  at  each  corner  of  the  mouth. 

The  next  stage  was  performed  some  three  months  later,  on  17.4.17,  and  included  the 
imbedding  of  a  cartilage  rod  beneath  the  periosteum  of  the  frontal  region.  The  periosteum 
was  made  partially  to  surround  the  cartilage. 

There  was  some  slight  suppuration  following  this  graft,  about  the  fourteenth  day 
after  the  operation,  and  a  small  incision  near  its  extremity  had  to  be  made.  The  condition 
rapidly  cleared  up,  but  the  cartilage  and  new  nose  were  not  brought  down  on  to  the 
face  until  some  five  months  later.  When  the  flap  was  outlined  and  raised  from  the 
forehead,  it  was  found  that  the  cartilage  that  had  been  there  so  long  had  made  a  bed  for 
itself  by  pressure  atrophy,  and  force  had  to  be  used  to  raise  it  from  its  bed.  A  large 
portion  of  the  under  surface  of  the  cartilage,  especially  near  the  attached  end  of  the  flap, 
would  therefore  have  been  exposed  to  the  nasal  cavity,  if  one  had  not  turned  down  the 


2GO 


PLASTIC    SURGERY 


>£ 


FlO.  506. — Shows  result  of  lip  operation  and  the 
cartilage  imbedded  in  the  frontal  flap. 


FIG.  507. — Diagram  of  the  rhinoplasty.  Note  :  the 
little  flap  D  was  all  that  was  provided  in  the  way  of 
epithelial  lining.  Hence  the  indifferent  result. 


small  skin-flap,  marked  D  in  the  diagram,  to  cover  this  portion.  (It  is  interesting  to 
note  that  at  this  stage  the  author  had  not  fully  realised  the  significance  of  the  skin-lining 
to  the  new  nose,  and  was  labouring  under  the  delusion  that  a  periosteal  layer  between  the 
cartilage  and  the  nasal  cavity  was  an  adequate  protection  from  sepsis.)  This  patient  had 
a  very  narrow  forehead,  and,  in  avoiding  the  hair-line,  the  flap  was  not  cut  big  enough. 
It  should  be  noted  that  an  extra  large  flap  was  necessary  in  order  to  cover  in  the  cheek 
defect  as  well. 

Considerable  difficulty  was  experienced  in  fitting  this  nose  into  position,  and  the  im- 
mediate result  was  only  moderately  satisfactory. 

In  order  to  imitate  the  natural  prominence  of  the  pre-maxilla,  the  tissues  of  the  cheek 
were  incised,  at  points  A'.  Relaxation  sutures  held  these  two  flaps  together,  and  this 
manoeuvre  deepened  the  upper  lip.  Relaxation  sutures  were  also  passed  from  one  cheek 
to  the  other,  underneath  the  new  nose. 

A  slight  intra-nasal  discharge  followed  this  operation,  but  it  cleared  up  with  syringing. 

The  pedicle  was  returned  on  4 . 10  . 17,  and  into  the  base  of  the  nose  a  small  homologous 
cartilage  graft  was  superimposed  on  the  previous  cartilage.  Over  the  undisturbed  granu- 
lations in  the  forehead  a  large  Thiersch-graft  was  laid,  and  bound  firmly  into  position  by  a 
covering  of  paraffin  wax  (No.  7),  gauze  and  bandages. 

The  after-history  of  this  case  is  unsatisfactory  except  as  regards  the  skin-graft,  which 
healed  perfectly.  The  homologous  cartilage  did  not  take,  and  infected  the  imbedded 
cartilage.  Six  months  later  all  the  cartilage  appeared  to  have  been  absorbed,  which  disaster 
is  due  to  its  becoming  exposed  to  the  nasal  cavity  on  its  under  surface. 

This  case  is  described  in  order  to  point  out  various  mistakes  of  which  one  has  become 
cognisant  after  the  events.  It  is  a  mistake  to  put  the  cartilage  under  the  periosteum. 
It  is  a  greater  mistake  not  to  line  the  new  nose  with  some  form  of  epithelium.  The  homo- 
logous secondary  cartilage  graft  was  an  injudicious  procedure. 


INJURIES    OF    THE    NOSE 


2G1 


FIG.  508.— Two  days  after  the  rhinoplasty.     The 
author  does  not  now  use  rubber  tubes. 


FIG.  509. — After  this  stage  the  pedicle  was 
returned  and  the  forehead  successfully  grafted. 
The  nose,  however,  owing  to  the  lack  of  epi- 
thelial lining  mentioned  in  the  text,  underwent 
considerable  diminution  in  size. 


This  case  is  also  of  interest  in  that  it  shows  the  difficulty  of  making  the  nose  on  an 
abnormal  bed.  Had  the  nose  been  a  good  one,  it  would  still  have  been  set  quite  1  in.  too 
far  back,  owing  to  the  loss  of  the  pre-maxilla,  which  loss  was  not  greatly  overcome  by  the 
flap  manoeuvre  carried  out  at  the  total  rhinoplasty.  It  would  have  been  better  had  one 
adopted  the  suggestion  of  Captain  Fry,  our  chief  Dental  Surgeon,  of  separating  the  new  lip 
from  the  maxilla  and  inserting  a  dental  plate  prior  to  the  operation  for  the  nose.  This 
can,  of  course,  still  be  done,  and  by  methods  that  are  described  in  later  cases  it  is  yet  possible 
to  procure  a  satisfactory  surgical  result. 

Another  case  done  by  my  late  colleague,  Captain  Aymard,  at  the  Cambridge  Hospital, 
Aldershot,  should  be  recorded,  as  it  is  an  evidence  of  an  effort  at  perfection  in  rhinoplasty 
marred  by  the  want  of  a  skin  lining. 

It  was  a  case  similar  to  the  one  just  described,  but  it  lacked  the  lateral  loss  which 
complicated  Case  111  ;  that  is  to  say,  the  bed  on  which  to  put  the  nose  was  normal.  Captain 
Aymard,  with  the  assistance  of  the  sculptor.  Lieutenant  Edwards,  made  a  model  of  the 
ideal  nose  in  plasticine,  and  then  reduced  this  by  the  thickness  of  a  forehead  flap.  The 
remains  of  the  mould  were  then  cut  into  sections,  and  cartilage  to  correspond  with  this 
undcrmould  of  the  nose  was  cut  from  the  costal  region. 

In  order  to  get  the  exact  shape  more  than  one  piece  had  to  be  used.  These  were 
stitched  together  with  catgut.  This  composite  block  of  cartilage  was  then  inserted  between 
the  skin  and  aponeurosis  of  the  frontal  flap.  The  appearance  for  some  weeks  was  remark- 
ably good,  but,  owing  to  the  lack  of  epithelium  on  its  under-surt'ace,  slow  ulceration  of  the 
cartilage  occurred,  with  subsequent  flattening  and  contraction  of  the  new  nose. 


PLASTIC    SURGERY 


CASE  145 

This  is  interesting  as  an  attempt  to  perform  the  author's  modified  operation.  It 
partially  failed,  hut  the  imbedded  cartilage  was  of  service  later  in  the  case,  when  a  modified 
Keegan-Smith  operation  was  carried  out. 

The  modified  operation  was  different  in  this  case  from  any  of  the  three  next 
described,  Nos.  140,  '298,  and  300,  in  that  the  pedicle  was  bilateral,  whilst  in  each  of  the 
other  three  cases  the  pedicle  was  unilateral. 

The  reason  for  this  difference  is  that  this  Case  145  has  its  anterior  nares  on  the  same 
level  each  side,  whilst  in  each  of  the  other  cases  one  was  at  a  higher  level  than  the  other. 
In  comparing  his  result  with  the  others,  one  notes  objectionable  features  in  the  use  of  double 
pedicles. 

The  result  was  fairly  satisfactory.       The  lengthening  of  the   nose  is  seen  in  photo 

(fig.  513).  The  imbedded  car- 
tilage is  fairly  evident.  An 
attempted  columclla  from  the 
upper  lip  at  the  same  time 
broke  down. 

Photos  of  the  result  of 
this  operation  were  taken  a 
year  after,  and  it  then  had  to 
be  decided  whether  a  corrective 
operation  to  complete  the 
rhinoplasty  on  its  existing 
basis  should  be  performed  or 
whether  the  method  should  be 
altered.  The  latter  course  was 
adopted,  and  the  condition 
was  now  really  only  one  of  the 
Indian  mutilation  type. 

The  turned-down  skin-flap 
to  line  the  new  tip  and  ala? 
was  made  to  contain  a  portion 
of  the  cartilage  of  the  previous 
operation. 

The  turned-down  flap  was 
partially  split  so  as  to  get  the 
Smith  variety  of  the  Kcegan 
operation. 

The  exciting  part  of  this  operation  was  the  frontal  flap,  because,  as  the  diagrams  show, 
the  scar  of  the  first  operation  ran  very  nearly  across  the  pedicle  of  the  frontal  flap.  Not- 
withstanding this,  the  blood  supply  was  quite  satisfactory,  and  the  procedure  appears  to 
be  justified. 

This  particular  patient  has  a  very  poor  resistance  to  infection,  and  at  the  return-pedicle 
operation  a  considerable  sepsis  of  the  forehead  wound  occurred.  A  skin-graft  to  make 
good  the  area  denuded  of  epithelium  failed  to  take. 

It  will  be  interesting  to  note  that  several  plastic  operations  had  been  attempted  on 
this  patient  prior  to  his  admission  to  our  clinic.  Twice  he  has  had  his  arm  tied  to  his  head 
and  an  Italian  operation  attempted.  Both  failed. 


Fio.  510. — Incisions  for  the  rhinoplasty. 


INJURIES    OF    THE    NOSE 


263 


FIGS.  51 1  and_512. — The  injury.     Loss  of  the  lower  halt  of  nose. 


FIG.  513.— Indifferent  result  of 
special  method  (used  in  the 
next  three  cases  described). 


FIGS.  514,  515,  and  510. — Result  of  making  new|tip  and  alaj  by  double  epithelial  flaps  and  cartilage. 

See  diagram  and  text. 


264 


PLASTIC    SURGERY 


CASE  140 

Thr  tvpe  case  is  No.  140.  Loss  of  the  tip  commencing  just  below  the  bony  bridge 
and  extending  down  to  the  base  of  the  columdla.  More  of  the  Iclt  ala  reg.on  was  lost 
than  on  the  right.  Bv  an  incision  which  is  shown  in  the  diagram  a  sk.n-flap  was  turned 
down  from  the  forehead.  The  incision  was  made  on  the  right  lateral  aspect  ol  the  nose 
from  the  junction  of  the  ala  to  remains  of  septum,  up  to  the  inner  margin  of  the  right  eye- 
brow, and  then  to  a  point  in  the  middle  line  of  the  forehead,  about  2m.  above  the  root 
,,f  the  nose.  The  skin  was  undermined  and  raised  off  the  bridge  of  the  nose  and  a  flap 
of  periosteum  2  in.  long  by  1  in.  broad  was  reflected  downwards  from  the  forehead,  being 
left  attached  in  the  glabellar  region. 

This  periosteum,  therefore,  came  to  lie  underneath  the  raised  flap  of  skin  and 

the  existing  nasal  bridge.  ,  . 

A  piece  of  cartilage  about  If  in.  in  length  was  now  taken,  and  wrapped  in  this  peric 
teum.     The  skin-flap  was  placed  over  this  imbedded  cartilage. 


\ 


FIG.  517. — Stage  1. — The  incision  for  the  insertion 
of  the  cartilage. 


FIG.  518. — Stage  2. — The  same  incision  extended 
so  that  the  advancement  can  be  made. 


Some  two  months  later  the  second  stage  was  performed.  It  consisted  of  an  incision 
along  the  right  side  of  the  nose  in  the  same  line  as  in  the  previous  operation.  At  its  lower 
end  the  knife  was  carried  deep  into  the  nasal  cavity.  A  corresponding  incision  was  made 
on  the  left  side,  commencing  from  the  mid-point  of  the  forehead  and  descending  along  the 
line  of  junction  between  nose  and  cheek  down  as  far  as  the  commencement  of  the  naso- 
labial  fold.  This  flap  of  skin  was  then  raised,  commencing  from  above.  At  the  point 
where  the  cartilage  was  met  the  knife  was  carried  deep,  so  as  to  raise  it  imbedded  in  the 
skin-flap.  At  the  point  where  the  existing  bony  bridge  ended  the  knife  was  carried 
deeply  into  the  nasal  cavity.  The  blood  supply  to  this  flap,  thus  detached,  came  from 
tlie  whole  thickness  of  the  left  ala  and  columclla. 

The  whole  flap  and  cartilage  could  now  be  advanced  downwards,  the  cartilage  producing 
a  satisfactory  support  to  the  new  tip.  The  upper  end  of  the  cartilage  graft  was  inserted, 
partly  under  and  partly  over,  the  nasal  bones  by  splitting  its  upper  end.  The  left  nasal 
opening  now  formed  a  satisfactory  new  left  ala,  and  was  brought  by  this  manoeuvre  to  the 
same  level  as  the  right  one. 

The  only  difficulty  in  suture  occurred  at  the' re-entrant  angle  on  the  left  side  between 
the  eye  and  the  nose.  A  small  flap  from  the  left  upper  lid  was  turned  down  to  complete 
the  closure. 

Secondary  corrections  of  the  tip  were  performed  later  with  satisfactory  result. 


INJURIES    OF    THE    NOSE 


265 


In  criticising  this  method,  as  evidenced  by  this  particular  case,  its  defects  would  appear 
to  be  that  the  tip,  in  this  method  of  swinging  it  down,  becomes  somewhat  depressed.  It 
gave  a  by  no  means  displeasing  effect  to  this  particular  patient. 


FIG.  519. — The  healed  stage. 


Fio.  520.— Profile. 


FIG.   521. — Result  of  the  advancement. 


Fio.  522.— Profile. 


266 


PLASTIC    SURGERY 


CASE  298 

The  next  case,  No.  298,  was  of  the  same  type,  but  of  a  very  much  smaller  degree,  and 
on  this  occasion  one  tried  to  get  over  the  difficulties  above-mentioned  Avith  Case  140  by  de- 
signing the  flaps  differently.  The  skin  was  advanced  from  the  cheeks  and  not  from  the 
forehead.  The  disadvantage  of  this  method  became  apparent  later,  as  there  were  two 
scar-lines  running  across  the  middle  line  of  the  new  nose,  whereas,  with  the  long  pointed 
flap,  the  skin  was  not  so  marred. 

An  effort  to  improve  the  tip  was  also  made,  and  a  shaped  piece  of  cartilage  (fig.  524) 
was  inserted  through  a  right  lateral  incision,  well  shown  in  the  photograph  (fig.  527). 

Here,  again,  the  left  ala  was  situated  at  a  higher  level  than  the  right,  and  the  imbedded 
cartilage  was  swung  down  with  its  blood  supply  from  the  columella  and  left  ala  (flap  X  in 
diagram). 

The  right  ala  was  sewn  to  the  nose-tip,  and  the  area  of  skin  along  the  bridge  of  the 
nose  caused  by  the  descent  of  flap  X  was  made  good  by  a  lateral  advancement  flap  A 
from  the  right  cheek  and  a  long  relaxation  cut  B — C  on  the  left  cheek.  The  early  result 


C 


FIG.  523. — Cartilage  was  imbedded  under  X.     X  is  then  advanced  with  its 
cartilage.     The  gap  is  made  good  by  lateral  advancement  of  flap  A. 


FIG.  524. — Shape  of  the  cartilage 
inserted. 


of  this  nose  was  not  good  from  a  cosmetic  point  of  view,  and  the  tip  could  not  be  brought 
down  sufficiently  owing  to  a  lack  of  sufficient  stalk  to  the  cartilage  with  which  to  gain  its 
purchase  from  the  existing  septal  bridge.  The  tip  has  a  tendency  to  be  blue. 

Eight  months  later  the  condition  was  very  much  improved,  and  a  following  corrective 
operation  was  performed. 

1.  Excision  of  the  redundancy  of  the  columella,  the  cartilage  in  this  columella  being 
removed  and  inserted  in  the  depression  in  the  nasal  bridge.  The  tip,  which  was  too  fat, 
especially  on  the  right  side,  was  reduced  by  excision  of  a  piece  of  cartilage  from  this  aspect. 

In  order  to  produce  a  roundness  of  the  tip  this  piece  of  cartilage  was  there  inserted. 

The  result  of  this  corrective  operation  was  very  satisfactory,  but  the  slight  tendency 
to  blucness  in  the  tip  has  temporarily  reoccurred. 

All  scars  are  rapidly  becoming  invisible. 


INJURIES    OF    THE    NOSE 


267. 


FIGS.  525  and  526. — Loss  of  the  tip  and  part  alae. 


FIG.  527. — Stage  1  :  Implanta- 
tion of  cartilage. 


FIGS.  528,  52'J,  and  530. — Result  after  advancement  of  skin  and  cartilage.     Note  :   the  nose  was  still  becoming 

thinner  and  more  shapely  when  last  seen. 


268  PLASTIC    SURGERY 

CASE  300 

The  third  of  this  scries  was  of  a  typical  Indian  mutilation  type,  but  the  left  ala 
was  again  at  a  higher  level  than  the  right.  The  diagram  shows  the  incision  of  the  first 
stage  at  which  the  cartilage  was  imbedded.  A  separate  piece  of  cartilage  was  imbedded 
in  the  left  ala  to  fill  this  out.  The  pcriostcal  bed  from  the  frontal  bone  was  similarly  turned 
down  underneath  the  cartilage.  (Diagram  531.) 

At  the  second  stage,  performed  four  months  later — 19.10.17 — a  flap  to  the  extent  and 

shape  shown  in  the  diagram 
was  raised  with  the  carti- 
lage and  slid  down  to  form 
a  tip.  A  small  prolonga- 
tion over  the  left  eye 
brought  over  the  frontal 
flap — not  in  diagram — was 

^u  v\V'\\  made  in  order  to  overcome 

J  WM---N— '«~*thc    difficulty    of    the    rc- 

//  «OT»%T  Periosteum    entrant    angle    when     the 

H~8Wn  advancement     had     taken 

H-  Cartilage  .  T  .    „ 

place.  It  was  satisfactory 
in  filling  the  gap,  but  was 
lost  through  failure  of  blood 
supply. 

The  immediate  result 
was  good,  but  there  were 
slight  irregularities,  due  to 
the  failure  of  the  small  flap 
to  live. 

All  these  three  cases  have  shown  good  results,  but  each  one  has  shown 
certain  difficulties  of  a  minor  character  which  have  not  been  solved.  The 
operation  has  the  very  great  advantage  of  producing  no  large  or  marked  scars 
anywhere,  and  those  that  are  made  are  in  the  lateral  aspect  of  the  nose  and  in 
the  midline  of  the  forehead. 

In  view  of  the  series  of  cases  done  by  the  Indian  method  it  would  seem 
that  this  operation,  if  capable  of  further  improvement,  would  supersede  the 
Indian  method  for  certain  types  of  minor  loss  of  the  tip  and  alee. 

One  disadvantage  not  previously  noted  in  regard  to  this  operation  is,  that 
the  new  tip  tends  to  be  cold  and  a  little  blue,  due  to  the  fact  that  the  mutilated 
tip,  when  healed,  has  a  considerable  amount  of  scar  tissue  over  it.  Time  has 
largely  rectified  this  in  my  cases. 

The  author  has  used  this  method  only  on  one  other  case  (Case  No.  145,  q.v.), 
but  on  this  type  the  operation  is  contra-indicated,  as  the  loss  is  too  severe,  and 
bilateral. 

The  later  examination  showed  a  quite  satisfactory  result,  except  that  the  left  ala  was 

somewhat  retracted,  causing  stenosis.     Ihe  columella  also  was  not  central  or  suflicieiitly 

Cartilage  from  the  antihclix  of  the  left  ear  was  imbedded  to  strengthen  the 

t  ala ;  at  the  same  time  scar  tissue  was  excised  and  skin  tucked  in  to  make  a  better  vesti- 

The  columcllar  attachment  was  divided  above  and  re-sewn  in  a  more  central  and 


INJURIES    OF    THE    NOSE 


269 


permanent  position.  The  final  result  was  good,  almost  as  good  as  if  a  successful  inturned 
and  frontal  flap  had  been  made  in  the  first  instance,  and  there  was,  in  addition,  the  great 
advantage  of  a  minimal  secondary  deformity.  . 


Fios.  532  and  533. — Loss  of  tip  and  part  ala\     All  the  free  edge  of  the  left  ala  is  destroyed. 


FIGS.  534,  535,  and  53fi.  — Result  of  advancement  operation  and  minor  corrections.     (Author's  method.) 


270 


PLASTIC    SURGERY 


CASE  583 

This  is  really  a  transition  case  from  our  previous  group,  and  there  is  hardly  more  than 
half  of  the  nose  gone ;  in  addition,  he  has  the  enormously  valuable  remains  of  the  akc. 
There  is  only  one  feature  about  the  case  which  is  different  from  the  type  of  operation,  and 
that  is  in  relation  to  the  external  flap,  which  was  cut  and  arranged  differently,  by  a  new 
method,  around  the  tip  and  al;e.  There  is  really  very  little  else  to  discuss  about  this  case, 
and  the  good  early  result  is  only  that  which  is  to  be  expected.  The  external  flap  was  cut 
differently  for  the  following  reasons:  (1)  One  has  realised  for  a  long  time  that  it  is  un- 
reasonable to  expect  to  be  able  to  make  a  perfectly  fitting  covering  for  the  nose  out  of  one 
flap — a  tailor's  cutter,  if  he  were  asked  to  clothe  a  nose,  would  not  make  his  suit  out  of 
one  piece  of  cloth  ;  there  would  be  some  accessory  pieces  for  the  delicate  curves  of  the 
nostrils  and  vestibule.  With  this  idea,  the  author  decided  to  make  the  columella  and  lobule 
out  of  two  lateral  flaps  brought  together  and  sutured  down  the  middle.  Situated  laterally 
to  these  flaps  two  further  pieces  were  cut,  one  on  each  side,  which  were  curled  in  upon 
themselves  and  were  to  represent  the  portion  of  the  ala?  that  had  to  be  made.  One  feels  that 
a  new  principle  underlies  this  new  method.  Something  similar  was  successfully  attempted 
in  Case  '203,  where  an  excellent  tip  was  also  produced,  and  it  is  probable  that  a  modification 
of  the  frontal  flap  on  some  lines  similar  to  these  two  cases  will  eventually  be  made.  Another 
frontal  flap  similar  to  that  of  Case  583  has  been  made,  but  the  case  K  in  too  early  a  stage 
to  be  sure  of  the  final  result.  Operation  details  are  appended  here  : 

18.7.18.  Operation. — Preliminary  intranasal  work  with  implantation  of  cartilage. 
Cartilage  from  7th  and  8th  costal  cartilage.  Skin  incision  extending  from  inner  side  of  each 
eyebrow  downwards  to  just  above  the  ala  on  either  side. 

Skin  undermined  and  cartilage  implanted.  The  incision  was  made  in  this  way  so  that 
the  flap  developed  its  own  blood  supply.  The  right  ala  was  separated  by  a  curved  incision 
running  through  the  alar  furrow,  and  the  skin  and  mucous  membrane  sutured  together. 


FIQ.  537. — Loss  of  lower  half  of  nose.     Nasal  stenosis. 


Fia.  538. — Profile  on  admission. 


INJURIES    OF    THE    NOSE 


271 


The  same  procedure  for  left  ala.  Incisions  were  carried  upwards  on  either  side  of  the  septum. 
A  small  V-shaped  portion  of  the  septum  was  excised  in  its  lower  portion,  and  the  skin 
was  sutured  to  mucous  membrane.  Tube  covered  with  vaseline  gauze  was  replaced  in  each 
nostril. 

Note. — Great  difficulty  was  experienced  in  sewing  the  skin  over  the  cartilage,  es- 
pecially on  right  aspect.  A  small  portion  of  cartilage  remained  exposed.  Kesult :  very 
satisfactory.  The  exposed  cartilage  was  not  infected,  and  was  rapidly  covered  by  epithelium. 
Nasal  airway  established. 


Fio.  539. — Result  of  the  important  first  stage.     (1)  Also  replaced  j  (2)  airway  established  ;   (3)  cartilage 
imbedded  over  glabella  and  bridge  of  nose. 

17.10.18.   Operation.     (2nd  Stage.) 

1.  Glabella  flap  swung  down  with  its  contained  cartilage. 

2.  The  exposed  portion  of  the  septum  was  incised  from  above  downwards,  thus  making 
a  slice  which  served  as  a  support  for  the  columella.     Its  back  surface  was  covered  by  the 
tip  of  the  turncd-in  glabella  flap.     The  alse  remains  were  freshened  and  partly  sutured  to 
this  same  flap. 

A  bifid  frontal  flap  of  special  design  was  brought  down  from  right  forehead. 

The  points  are  : 

The  lobule  and  columella  were  made  by  bringing  two  lateral  flaps  together  while  two 
further  lateral  flaps  were  turned  in  on  themselves  to  complete  the  remaining  portion  of 
the  ala?.  The  tips  of  these  inturned  flaps  were  sutured  to  the  original  glabella  flap. 

The  antero-latcral  aspect  of  the  columella  was  denuded  of  epithelium  to  receive  the 
above-mentioned  columella  flaps. 

Result. — On  the  table  looked  very  satisfactory.  No  attempt  made  to  close  or  graft 
forehead  wound.  Later :  satisfactory,  but  the  inturned  flaps  to  complete  the  ala?  broke 
away  a  little,  which  somewhat  spoilt  the  line  of  the  new  ala;. 

18.1.19.  Operation. — Pedicle  returned  to  forehead.  Scar  tissue  excised,  and  a  whole 
thickness  skin-graft  applied  to  remaining  raw  area  on  forehead  to  readjust  hair-line. 


272 


PLASTIC    SURGERY 


FiO.  540. — Cast  taken  after  first  operation,  showing  incisions  for  (1)  inturned  skin-cartilage  flap  ; 

(2)  special  bifid  frontal  flap. 


I'm.  .11 1.— 1.  The  skin  cartilage  llii|  1 1ms  brcn  in  tun  in  I. 

I  h.    i-il^o;  of  nl;i'  iiiul  columella  freshened.     :!.   The 

liilid  frontal   flop  is  about  to  be  sutured  into  place. 

Note  the  formation  of  tip  and  columella  by  the  two 

-      a. 


FIO.  542. — Suture  of  the  frontal  (lap.  Note  the 
inturnrd  portion  at  A  and  D  to  complete  vestibular 
rpil  lirliuin. 

Note.— The  suture  line  of  the  forehead  is  incorrect. 
See  text. 


INJURIES    OF    THE    NOSE 


273 


FIGS.  543  and  544. —  Profile  views  soon  after  return  pedicle  operation.     The  Wolfe  graft  to  the  forehead 

has  not  yet  healed  round  its  edges. 


FIGS.  545  and  5lG — Early  finals. 


18 


•274 


PLASTIC    SURGERY 


CASE  183 


This  patient  entered  the  clinic  with  a  sub-total  loss  of  the  nose.  The  upper  portion 
of  the  bony  bridge  remained,  whereas  the  lower  part  was  a  mass  of  skin  and  cartilage,  the 
debris  of  previous  plastic  operations.  There  was  also  a  "  mucous  membrane  columclla," 
the  redness  of  which  completed  the  unpleasantness  of  the  effect.  Marked  nasal  obstruc- 
tion was  present. 

It  was  decided  to  swing  down  a  flap  of  skin  which  contained  cartilage,  to  form  the 
lining  of  the  nasal  tip  and  vestibules,  at  the  same  time  to  cut  away  the  mucous  membrane 
columella  and  to  re-establish  the  airway.  This  operation  was  performed  on  14.2.18. 
It  may  be  divided  into  three  stages :  (1)  The  mucous  membrane  columella  was  excised  ; 
(2)  the  triangular  flap  was  cut  from  the  existing  nose  and  swung  downwards,  skin  surface 
inwards.  The  extremity  of  this  flap,  which  formed  the  back  of  the  columella,  was  stitched 
to  a  raw  area  on  the  upper  lip  made  for  its  reception.  In  order  to  give  support  to  the  new 
tip,  the  cartilage  that  had  previously  been  imbedded  was  sectioned  from  above  downwards, 
until  its  extremity  could  be  stitched  to  the  raw  surface  of  the  first  flap  in  the  situation  of 
the  tip.  A  portion  of  the  cartilage  was  also  left  down  the  columella.  There  was  a  natural 
tendency  for  the  cartilage  to  spring  upwards.  (3)  Ihe  whole  raw  area  was  covered  by  a 
forehead  flap  carried  on  a  small  pedicle,  the  exact  size  of  which  is  seen  in  the  appended 
diagram.  The  forehead  was  closed  by  approximation,  a  circular  silver  wire  suture  being 

used.  Healing  was  exceptionally  good,  and  save 
for  a  breaking  away  of  the  upper  lip  from  the  new 
columella — which  was  probably  due  to  the  spring 
of  the  cartilage — no  untoward  result  occurred.  The 
pedicle  was  returned  four  months  later  and  the 
columella  reattached  to  the  upper  lip. 

Further  adjustments,  under  local  aiuesthesia, 
were  made  on  two  later  occasions,  and  a  small 
piece  of  cartilage,  from  another  case,  was  inserted 
through  the  columella  to  give  more  prominence  to 
the  tip. 

The  patient  was  discharged  on  21.1.19,  the 
nose  looking  very  natural  and  having  a  good 
airway.  On  cold  days,  or  when  exposed  in  a  car, 
this  nose  gets  blue  at  the  tip,  but  not  more  so  than 
a  great  number  of  natural  noses.  The  suture  line 
between  the  new  nose  and  side  of  the  cheek  is 
almost  imperceptible;  entirely  on  the  left,  and 
nearly  so  on  the  right. 

The  history  of  this  case  teaches  a  lesson. 
Originally  there  was  total  destruction  of  all  the 
supports  except  that  of  the  upper  part  of  the 
bridge,  and  the  remaining  skin  of  the  nose  was 
lying  flat  in  front  of  the  nasal  aperture.  Several 
attempts  at  cartilage  implantations  and  small 
cheek-flaps  had  been  made  with  indifferent  results 
prior  to  one's  taking  over  the  case.  In  addition,  a 
mucous  membrane  columella  had  been  brought 
from  the  upper  lip  in  the  region  of  the  nasal 
spine. 

In  view  of  our  later  methods,  all  this  diflicult  work  that  had  been  performed  was  on 
entirely  wrong  lines.  The  addition  of  the  pouting  mucous  membrane  columella  had  not 
OTlly  a  horrible  appearance,  hut  also  seriously  blocked  the  airway. 


Fio.  547. — Composite  cast  showing  incisions 
for  rhinoplasty  and  the  excision  of  the  mucous 
membrane  columella  that  had  been  made  prior 
to  admission. 


INJURIES    OF    THE    NOSE 


FIGS.  548,  549,  and  550.— Condition  on  admission.      Cartilage  had  been  implanted  in  the  nose  to  raise  the 
bridge  without  satisfactory  result.     A  columella  had  been  made  out  of  lip  mucous  membrane. 


FiQ3.  551,  552,  and  53;i. — -Pictures  of  tho  rosult.     Tho  pedicle  in"jthis  case  was  returned  to  the  forehead,  the 
balance  of  the  raw  area  of  which  was  closed  by  approximation  and  healed  scar. 


276 


PLASTIC    SURGERY 
CASE  385 


This  case  is  interesting  in  that  it  is  a  stepping-stone  to  much  of  the  present-day  rhino- 

plasty. 

Previous  to  this,  one  designed  the  "  Vallancey  swing  "  (for  the  pug-nose  type)  without 

quite  realising  its  significance. 

This  was  the  first  considerable  loss  of  the  nose  repaired  in  our  clinic  by  shaping  inturned 
flaps,  and  the  support  was  provided  by  a  removable  mechanical  appliance  resting  in  an 
epithelial  cavity,  while  the  outside  covering  was  of  the  usual  type.  This  apparatus  was 
designed  by  the  late  Captain  Robertson  and  is  illustrated. 

In  reviewing  this  case,  one  is  sure  that  a  better  result  would  have  been  obtained  had 
cartilage  been  provided  in  the  inturned  flap  and  for  the  alae.  In  our  experience,  any  form 
of  intranasal  support  is  liable  to  produce  chronic  irritation  and  stenosis.  These  two  fleshy 
flaps  making  the  nose  gradually  took  up  a  position  shown  in  fig.  560,  which  is  considerably 

lower  than  immediately  after  the  operation.  In  addition, 
epithelial  grafts  had  to  be  applied  to  the  anterior  nares  to 
give  stability  to  the  airway. 

The  patient  is  quite  satisfied  with  the  result,  and  it  is 
certainly  an  interesting  case  so  far  as  the  later  develop- 
ment of  rhinoplasty  is  concerned.  One  year  after  the 
restoration,  the  junction  of  the  new  nose  and  cheek  is 
almost  invisible,  and  the  colour  of  the  nose  is  so  natural 
that  its  deficiencies  in  form  are  greatly  minimised.  It 
should  be  noted  that  a  very  narrow  pedicle  was  employed 
for  the  frontal  flap.  Secondary  deformity  of  forehead 
whence  the  flap  was  taken  is  minimal,  while  the  airway  is 
sufficient  without  being  free. 

25.9.17.   Operation. — For  establishing  nasal  passage. 
26.10.17.— Nasal  splint,  with  tubes,  fitted. 
9.11.17. — Previous  operations  unsatisfactory.     Nasal 
stenosis  present.     Operation  for  cure. 

1.  Circular    incision   in   a   free   manner    round    nasal 
aperture. 

2.  Impression  of  aperture  taken  in  dental  wax. 

3.  The  grafts  were  then  laid  over  the  parts  which  were 
in  contact  with  the  raw  surfaces. 

4.  The  mould  and  grafts  were  then  placed  into  position 
and  held  there  by  strapping. 

5.  Two  airways  were  made  through  the  model. 
Result. — Perfect  epithelialisation,  except  in  the  floor  of 

the  left  nasal  passage.  A  very  good  quality  of  skin  was 
produced  on  right  side.  Slight  stenosis  of  left  passage  re- 
mains. General  result  satisfactory. 

Note. — This  method  is  an  adaptation  of  the  inlay,  and 
might   be    called    a   semi-open    epithelial    method.      Note 
the    disadvantage    on    the   floor    of   the    nose,    owing  to 
secretions  collecting  at  that  spot. 

30.1.18.  Operation.— Rhinoplasty.  Sub-total,  1st  stage.  (Oil  ether.) 
Reformation  of  lower  two-thirds  of  the  nose  by  means  of  double  epithelial  flaps  sup- 
ported by  temporary  vulcanised  splint  (splint  made  beforehand,  and  accurately  fitted  the 
floor  of  the  nose).  The  skin  of  existing  portion  of  nose  was  turned  down  at  a  flap  A,  B, 
A,  on  a  hinge  represented  in  diagram  by  dotted  line,  which,  in  reality,  was  the  margin  of 
the  existing  nasal  aperture. 

This  flap,  when  turned  down  over  the  splint,  formed  the  skin  lining  for  the  new  nose, 


Fio.  554. — Vulcanite  intranasal 
support  in  three  pieces,  over  which 
the  double  epithelial  flaps  were 
moulded.  This  apparatus  was 
made  by  the  late  Captain  E.  G. 
Robertson,  attached  R.A.M.C. 


INJURIES    OF    THE    NOSE 


277 


including  the  ala  and  the  back  of  the  columella.  Portion  of  the  lip  skin  A  was  turned 
upwards  to  meet  B  and  to  complete  the  posterior  lining  of  the  columella.  A  model  of 
the  raw  area  in  stent  was  then  made  and  outlined  on  the  forehead.  The  flap  was  cut  and 
swung  down  into  place,  completely  covering  all  raw  area. 

It  will  be  noticed  that  the  extremity  of  the  frontal  flap  was  sutured  into  the  upper  lip. 

The  total  appearance  was  very  satisfactory.     Healing  by  first  intention,  and  exception- 


Fio.  555.— Diagram  of  the  inturned  flap  B  and  of  the  forehead  flap.     The  hinge  on  which  B  was  turned 

over  is  indicated  by  a  dotted  line. 

ally  good  scars  obtained  on  the  lateral  nasal  aspect.  Stitches  removed  third  and  fourth 
days. 

The  pedicle  was  a  bridge  pedicle.  Treatment  of  central  frontal  gap  by  silver  wire 
suture.  No  skin  graft. 

12.2.18.   Operation. — 2nd  stage. 

Bridge  pedicle,  separated  from  grafted  portion,  returned  to  forehead.  A  cut  was  made 
into  this  pedicle  to  elongate  it.  The  cut  nasal  end  of  pedicle  was  imbedded  into  the  nose. 


•278 


PLASTIC    SURGERY 


FIG.  556. — The  injury  on  admission. 


FIG.  557.— Profile. 


Fio._558.— After  establishment  of  nasal  airway  by  excision  of  scar  and  Thiersch  graft. 


INJURIES    OF    THE    NOSE 


279 


FIG.  559. — Result.     Pedicle  returned  to  forehead. 


FIG.  500. — Profile.     Note  :   no  cartilage  support  was  used  in  this  case,  which  would 
undoubtedly  have  improved  its  lines. 


PLASTIC    SURGERY 


CASE  632 

This  gunner  lost  the  lower  two-thirds  of  his  nose  by  gunshot  on  15.1.18,  and  was 
admitted  three  months  later  to  the  clinic. 

There  was  almost  complete  stenosis  from  scar  tissue,  and  the  first  necessity  was  to 
establish  a  breathing  passage.  This  was  kindly  undertaken  by  Major  Justin  M.  Waugh, 
M.R.C.  (U.S.).  On  the  left  side  some  remains  of  the  vestibule  could  be  utilised  in  the 
repair.  Shortly  after  that  Major  Waugh  was  called  to  other  fields  of  activity,  and  one 
established  the  airway  on  the  left  side  on  the  visual  lines,  having  given  up  the  idea  of  using 
these  small  remains  of  vestibule.  At  the  same  time,  cartilage  was  imbedded  into  the  pro- 
jected "  turned-in"  flap.  A  further  thin  rod  of  cartilage  was  implanted  in  the  left  cheek, 
which  was  a  new  method  of  making  the  ala.  The  idea  was  that  a  combined  skin  and 
cartilage  flap  should  be  turned  in  as  a  lining  to  the  vestibule  and  a  support  to  the  ala.  It 
is  the  same  principle  as  the  Vallancey  Swing.  The  natural  spring  of  the  cartilage  should 
prevent  any  atresia  of  the  nares.  A  most  satisfactory  ala  was  thereby  secured.  A  special 
design  of  the  frontal  flap  was  made  in  this  restoration.  The  tip-columella  portion  of  it. 
was  cut  considerably  longer  than  necessary,  and  when  brought  into  position  on  the  new 
nose  this  redundancy  was  dealt  with  by  making  the  flap  curl  back  upon  itself  over  the  tip. 
Stitches  were  put  in  laterally  to  maintain  this  fold.  It  gives  a  bizarre  appearance  at  the 
time  of  operation,  appearing  like  a  square  projection  at  the  end  of  the  nose ;  but  one  felt 
sure  that  this  would  round  itself  off.  As  the  photographs  show,  a  most  excellent  tip  was 
the  result. 

This  case,  No.  583,  and  another  case  not  illustrated,  all  show  definite  attempts  to 
produce  a  new  and  better  kind  of  lobule.  Details  of  operations  follow  : 

29.6.18.  Operation. — Establishment  of  nasal  airway.  Result  is  satisfactory  on  right 
side.  Healed  well. 

10 . 8 . 18 .   Operation. — (1)  Cartilage  imbedded  into  root  of  nose  for  later  "  swing  down." 


Fio.  661. — Loss  of  lower  two-thirds  of  nose. 
Complete  atresia  of  nose. 


FIG.  562, — Profile  showing  the  loss  of  contour. 


INJURIES    OF    THE    NOSE 


281 


(2)  Small  rod  of  cartilage  was  imbedded  in  cheek  on  left  side  for  later  support  to  left  ala. 
Remains  of  right  ala  freed  and  brought  down  into  position.  Skin  sewn  to  mucous  membrane 
all  round  nasal  aperture. 

Result. — Satisfactory. 

10.10.18.  Operation. — (1)  Glabella  flap,  with  its  contained  cartilage,  swung  down 
inverted.  Extremity  of  flap  split  into  two  halves,  which  were  twisted  raw  surface  to  raw 
surface  to  make  lower  part  of  columella,  a  small  circular  area  in  upper  lip  being  bared  to 
receive  it.  (2)  Remains  of  right  ala  freed  and  its  edge  pared.  (3)  Small  flap,  with  contained 
rod  of  cartilage,  turned-up  skin  surface  inwards  to  form  vestibule  and  support  of  left  ala, 
sutured  to  the  skin  of  flap  1. 

Note. — The  cartilage  in  flap  1  was  now  sticking  out  very  prominently,  and  a  portion 


Fio.  563. — Shows  clearly  the"  establishment  of  the 
nasal  airway  by  scar  excision  and  suture  of  skin  to 
mucous  membrane.  A  cartilage  rod  has  been  inserted 
over  the  bridge  of  the  nose  and  glabella,  and  a  small 
lamina  into  the  cheek  for  the  ala  support. 


Fio.  564. — Incisions  for  the  next  stage  :  the  two  flaps 
containing  cartilage  are  inverted.  The  right  ala 
stump  is  advanced  and  the  forehead  flap  brought  down. 


was  excised  from  the  extremity.  The  lining  membrane  was  completed  by  catgut  suture 
of  these  three  component  flaps. 

(4)  Flap  of  required  size  cut,  brought  down  from  forehead. 

Note. — Left  ala  looks  exceptionally  well. 

A  special  doubling  of  the  extremity  of  the  forehead  flap  (see  diagram)  was  carried  out 
with  the  idea  of  giving  more  prominence  to  the  tip. 

The  immediate  effect  was  bizarre.     Forehead  closed  by  approximation. 

24.10.18.   Progress. — Satisfactory.     Tip  contracting  into  very  good  shape. 

The  pedicle  has  not  yet  been  dealt  with  owing,  amongst  many  other  things,  to  the 
present  influenza  epidemic.  It  is  proposed  to  deal  with  it  by  excision,  then  by  replacement, 
with  the  addition  of  a  whole-thickness  graft  in  the  upper  portion  of  the  scar  to  allow  the 
eyebrow  to  descend. 


282 


PLASTIC 'SURGERY 


Fio.  565. — Lateral  view  before     Fio.  566. — Suture  of  the  inturned  flaps      FIG.  567. — Lateral  view 
covering  flap  is  brought  down.  and  advanced  right  ala.  with  covering  flap. 

Note  that  the  split  ends  of  the  inturned  bridge-flap  are  turned  together  so 
that  their  skin  surface  forms  the  columella. 


Fio.  508.— Suture  of  the  frontal  flap.     The  forehead  was  closed  by  approximation 
the  exact  lines  of  this  are  not  indicated  in  the  diagram. 


INJURIES    OF    THE    NOSE 


283 


FIGS.  509  and  570. — Views  of  the  nose  with  the  pedicle  in  position. 


FIG.  571. — Pedicle  returned.  FIG.  572.— Profile.     Compare  with  original. 

Note  the  slight  notch  in  right  ala,  which  was  due  to  an  error  in  diagnosis  of  the  amount  of  ala  lost. 
The  new  method  of  making  the  left  ala  gave  an  excellent  result,  as  shown  by  this  case. 


284  PLASTIC    SURGERY 

CASE  365 

The  first  photograph  shows  early  result  of  a  very  serious  injury.  In  addition  to  de- 
struction of  the  left  eye,  and  deformity  of  the  upper  eyelid,  the  lower  two-thirds  of  the  nose 
was  destroyed  as  well  as  the  pre-nuixilla  and  the  greater  portion  of  the  upper  lip.  There 
remained  about  one-third  of  the  upper  lip  at  the  left  corner.  The  condition  on  arrival, 
some  twelve  days  after  injury,  and  that  when  all  wounds  were  firmly  healed,  arc  shown  in  the 
photographs.  On  29.11.17  an  operation  was  performed,  as  a  first  stage,  on  the  upper 
lip,  to  construct  a  bridge  on  which  the  new  nose  could  be  made. 

As  no  photos  of  this  intermediate  stage  are  available,  this  operation  is  not  illustrated. 
It  was  intended  only  as  a  partial  repair  of  the  lip.  As  regards  the  rhinoplasty,  the 
principle  of  building  a  double  epithelial  nose  over  a  mechanical  intranasal  support  was  the 
one  employed,  in  the  hope  that  more  definite  shape  might  result. 

The  operation  was  planned  on  a  plaster  cast.  Into  the  nasal  aperture  was  fitted  an 
undermould  of  the  new  nose,  which  was  made  in  hardened  wax,  having  a  breathing  tube 
inserted  in  its  middle.  This  apparatus  was  constructed  under  the  direction  of  Captain 
Kelsey  Fry  and  is  not  illustrated.  Over  this  undermould  were  swung,  first  a  flap  from 
above  to  line  the  bridge  portion  and  back  of  columella,  and,  secondly,  two  lateral  skin- 
flaps  of  special  design  to  line  the  new  ala,  the  end  of  the  central  flap  being  attached  to  a 
small  skin-flap  turned  upwards  from  the  upper  lip.  When  this  had  been  carefully  sutured 
together,  a  piece  of  cartilage  was  taken  from  the  rib  and  a  piece  of  the  necessary  shape  was 
sutured  centrally  to  the  remains  of  the  nasal  bones.  Over  the  whole  was  brought  a  frontal 
flap.  No  skin  grafting  was  carried  out.  The  pedicle  of  this  frontal  flap  was  of  the  imbedded 
variety  and  not  bridged  over  healthy  skin. 

The  result  of  this  operation  was  very  satisfactory.  Slight  delay  in  healing  occurred 
round  the  margins  of  the  ala,  a  spot  that  frequently  heals  with  difficulty. 

The  mould  was  retained  for  some  ten  days,  at  which  time  it  was  unwisely  removed. 
This  removal  allowed  the  tissues  to  thicken  on  the  under-surface  of  the  cartilage,  and  fill 
in  the  cavity ;  at  the  same  time,  a  fibrotic  process  commenced  around  the  ala  and,  to  one's 
disappointment,  this  result  was  marred  by  nasal  stenosis,  requiring  a  definite  operation 
for  cure. 

A  special  reimplantation  of  cartilage  was  made  eight  months  later,  in  which  one  central 
rod  was  supported  by  two  ala  rods  inserted  through  the  tip.  Subsequent  to  this,  all  tissues 
on  the  nasal  aspect  of  these  ala  cartilages  were  excised  and  the  columella,  which  was  too 
short  and  contracted  to  allow  the  tip  to  rise,  was  cut  across.  The  whole  raw  area  was  skin- 
grafted  by  thin  Thiersch  graft  held  in  position  by  a  piece  of  black  gutta-percha. 

The  graft  has  taken  well,  and  the  tip  is  now  upstanding  and  the  airway  established. 
This  case  is  completed  by  the  insertion  of  an  artificial  columella  (Captain  Kelsey  Fry), 
which  gives  support  to  the  tip  and  a  satisfactory  appearance.  There  are  no  normal  tissues 
in  the  neighbourhood  from  which  a  columella  might  be  made.  A  better  and  quicker  result 
would  have  been  obtained  had  the  cartilage  been  imbedded  at  the  preliminary  stage  on  the 
usual  lines. 

Details  arc  appended. 

Condition. — Loss  of  two-thirds  of  upper  lip,  lower  two-thirds  of  nose,  and  pre-maxilla. 

29.11.17.  Operation. — For  upper  lip.     First  stage. 

At  the  end  of  the  operation  there  still  remained  the  provision  of  the  skin  for  the  right 
half  of  the  upper  lip,  for  which  a  bridge-flap  seemed  indicated  :  as  in  view  of  a  later  rhino- 
plasty, a  descending  lateral  nasal  flap  was  not  indicated.  The  bridge  flap  was  not  attempted 
at  this  operation,  and  the  raw  gap  was  closed  by  drawing  up  the  mucous  membrane  to  meet 
the  skin  on  the  right  side  of  the  lip. 

A  denture  was  inserted  to  support  this  lip. 

•J.',.3.18.   Operation.— Sub-total  rhinoplasty — varied  Indian  method. 

A  hard  wax  mould  was  made  with  the  assistance  of  Captain  Fry,  in  which  was  imbedded 
a  small  breathing-tube.  Over  this  mould  the  new  nose  was  made  in  the  following  manner. 
Three  skin-flaps  were  turned  inwards,  one  from  the  bridge,  and  two  from  the  cheek  region, 


INJURIES    OF    THE    NOSE 


285 


Fio.  573. Loss  of  the  lower  two-thirds  of  the  nose  complicated  by  loss  of  the  pre-masxilla  and  upper  lip. 


FIG.  574. — The  healed  condition.  The  accom- 
panying bony  and  lip  destruction  makes  the 
rhinoplasty  considerably  more  difficult. 


FIG.  575. — Profile  view  of  the  lost  contour. 


28C, 


PLASTIC    SURGERY 


to  complete  the  underlining  of  the  new  ala  and  back  of  columclla.  The  lateral  Haps  were 
of  special  design.  These  flaps  were  all  sewn  together,  and  the  raw  area  thus  created  was 
covered  by  a  frontal  flap.  Costal  cartilage  inserted  between  the  two  skin  layers  in  the 
centre  line.  Cartilage  extended  from  the  root  of  the  existing  nose  to  the  tip  of  the  new 
nose.  Spare  piece  of  cartilage  imbedded.  The  pedicle  was  very  narrow  and  was  imbedded. 
Result  very  satisfactory.  The  wax  support  was  removed  on  the  seventh  day.  It  should 
have  been  retained  for  a  considerable  time  longer,  as  thickening  of  the  tissues  and  stenosis 
are  occurring. 

16.4.18.   Operation. — Return  of  pedicle  to  forehead.     No  skin  graft. 
3.5.18.   Operation. — Upper  lip.     Second  stage. 

19.11.18.  Condition. — Result  of  lip-flap  not  pleasing  at  first,  later,  it  settled  down. 
Nasal  stenosis  is  now  almost  complete,  and  the  piece  of  cartilage  inserted  at  rhinoplasty 
operation  is  almost  flat  on  the  face  and  is  not  acting  in  any  way  as  a  support.  It  was  de- 
cided to  superimpose  another  piece  of  cartilage  to  give  more  support  and  prominence. 

19.11.18.  Operation. — A  piece  of  cartilage  from  store  in  abdomen  was  inserted  into 
each  ala  to  support  the  central  rod.  Diagram  of  method  to  support  herewith.  No  attempt 
to  establish  airway. 

Result. — Satisfactory. 

19.12.18.  Operation. — Excision  of  scar  on  edge  of  ala  and  of  tissue  beneath  the  alar 
cartilages,  coluniella  divided,  and  raw  area  beneath  tip  and  ala  skin  grafted  (Thiersch). 
Result  good. 


Kio.  570. — Diagram  of  operation  of  19.11 .18,  showing  implantation  of  three  rods  of  cartilage  to  raise  and 
support  the  newly  made  pose,  which  had  sunk  on  the  face  so  that  the  airway  was  occluded. 


INJURIES    OF    THE    NOSE 


287 


Fio.  577. — Showing  Stent  to  keep  Thiersch  graft  in  position.     It  is  perforated  for  airway. 


FIGS.  578  and  579.— Present  condition  ;    patient  wearing,  temporarily,  an  artificial  columella. 


288  PLASTIC    SURGERY 

CASE  517 

This  is  very  nearly  a  complete  loss  of  nose.  This,  again,  was  made  with  two  skin- 
flaps  without  support,  and  one  was  astonished  to  find  what  a  good  nose  resulted,  although, 
of  course,  it  was  rather  shapeless  and  there  was  a  tendency  to  stenosis  of  the  nares.  Silver 
tubes  were  fitted  to  keep  these  nares  open,  but,  in  my  opinion,  they  only  increased  the 
cicatricial  contraction.  It  was  therefore  decided  to  allow  the  passage  to  be  temporarily 
occluded  and  to  be  skin-grafted  at  a  later  stage ;  also,  to  build  up  the  contour  of  the  nose 
by  cartilage  implantations.  The  first  and  larger  implantation  had  the  effect  of  raising  the 
bridge  without  raising  the  tip.  This  was  three  months  after  rhinoplasty,  and  the  graft 
was  quite  satisfactory  and  the  nose  began  to  have  shape.  A  most  disastrous  mistake  was 
made  by  operating  again  upon  this  patient  19  days  later.  On  this  occasion,  further  shaped 
cartilage  for  the  tip  and  lower  parts  of  the  bridge  and  alae  was  implanted.  The  wounds 
healed  well,  the  stitches  were  out.  and  at  this  time  it  appeared  to  be  the  best  nose  the  author  had 
ever  made.  However,  on  the  eighth  day  after  this  operation,  an  abscess  formed,  and  the 
last  bridge  cartilage  was  evacuated.  When  healed,  the  result  was  most  unpleasant,  as  the 
skin  was  blue  and  wrinkled  ;  and  I  doubt  whether  the  nose  will  ever  be  as  good  again.  The 
cause  of  this  failure  was  undoubtedly  twofold:  (1)  operating  on  the  patient  too  soon; 
and  (2)  irritation  and  late  infection,  probably  caused  by  patient. 

After  a  considerable  interval  further  cartilage  rods  were  inserted  for  the  tip  and  ala 
supports,  the  nasal  surface  of  which  it  is  proposed  to  epithelialise  at  a  later  date,  to  establish 
the  airway.  Operation  details  appended  : 

5.3.18.  Operation. — Rhinoplasty,  sub- total  Indian  method:  a  central  and  two  lateral 
flaps  were  turned  in. 

The  extremity  of  the  central  one  was  sutured  to  the  upper  lip  to  form  the  back  of  the 
columella.  Frontal  flap  superimposed. 

N.B. — No  support  in  the  nose  or  in  the  new  tissues  brought  down. 

16.4.18.   Operation. — Pedicle  returned. 

Right  costal  cartilage  implantation.     Two  large  pieces  put  in  for  nose  and  eye. 

Skin-graft  over  the  undisturbed  granulations.  A  piece  of  whole-thickness  skin  the 
size  of  a  florin  was  implanted.  Its  edges  were  sewn  tight  to  the  edges  of  the  wound  and  a 
piece  of  stent  superimposed  to  put  it  on  tension,  the  edges  being  slightly  undermined  to 
retain  the  stent. 

Result  satisfactory.  Tendency  to  stenosis  of  nares.  Skin-graft  to  forehead  successful, 
pink,  soft  and  mobile. 

8.6.18.  Operation. — A  piece  of  cartilage  was  taken  from  subcutaneous  store,  shaped 
in  form  of  rod  and  inserted  from  the  root  of  the  nose.  Balance  of  cartilage  rcimplanted  in 
subcutaneous  tissue.  This  implantation  raised  the  bridge,  but  produced  a  certain  amount 
of  depression  of  the  tip  (comparative  rather  than  actual).  It  had  been  decided  to  allow 
stenosis  of  the  anterior  nares,  the  passages  to  be  re-established  later. 

Result. — Satisfactory. 

27.6.18.  Operation. — Further  implantation  of  cartilage  to  give  form  to  the  tip  and 
lower  part  of  bridge  and  alae.  Two  long,  thin  strips  were  inserted  through  a  vertical  in- 
cision just  below  the  tip.  The  skin  of  the  margin  of  each  ala  was  undercut  with  a  fine 
knife  as  far  as  the  cheek  attachment.  In  these  two  subcutaneous  tunnels  the  thin  bits 
of  cartilage  were  inserted.  A  third  main  piece  was  then  inserted  between  the  skin  and  the 
previous  cartilage  rod.  which  gave  a  very  fine-edged  bridge  effect.  An  eyelid  plastic  was 
also  performed  at  the  same  sitting. 

Result. — Xo  trouble  occurred  and  stitches  all  out,  but  on  eighth  day  nose  suppurated 
and  to  be  reopened  (5.7.18).  Pus  and  the  last  bridge  cartilage  were  evacuated.  Drainage. 
8.10.18.  Operation.—  Transfer  of  piece  of  cartilage  from  No.  681  for  future  use. 

13.12.18.  Operation.— The  above  piece  of  cartilage  was  inserted  in  tip  and  bridge. 
Result"  healed. 


INJURIES    OF    THE    NOSE 


289 


FIG.  580. — As  received  into  hospital.  FIG.  581. — Profile  healed. 


FIG.  582.— Healed. 


FIGS.  583  and  584.— Result  of  rhino 

partia 


:'hinoplasty  and  epithelial  outlay  for  upper  lid.     Note  the  defect  of  the  tip  and 
artial  naeal  stenosis,  for  the  cause  of  which  see  text. 


the 


19 


290 


PLASTIC    SURGERY 


CASE  23 

This  patient  lost,  by  shell-wound,  all  the  bony,  cartilaginous  and  soft  tissues  of  the 
nose,  with  the  exception  of  half  the  tip  and  the  adjacent  left  ala.  This  small  remaining 
portion  of  the  nose  had  not  fallen  back,  and  did  not  produce  the  pug  type  of  nostril  owing 
to  the  support  of  a  small  portion  of  the  septum  nasi  underneath  the  tip,  from  which  it  ex- 
tended backward  a  half  inch. 

This  case  has  many  interesting  features.  First,  a  natural  bridge  was  formed  by  tur- 
binate  grafting  and  advancement,  the  details  of  which  are  set  forth  later.  This  turbinate 
bridge  formed  a  natural  lining  to  the  frontal  flap.  Secondly,  additional  support  was  given 
this  frontal  flap,  both  in  regard  to  the  bridge  of  the  nose  and  the  right  ala,  by  shaped  celluloid 
plates.  These  gave  trouble  and  had  to  be  removed.  Thirdly,  this  nose  was  lined  by  (a) 
mucous  membrane  in  its  upper  half,  and  (b)  skin  in  its  lower  half.  This  skin  was  derived 
from  the  extremity  of  the  frontal  flap,  which  was  tucked  well  into  the  nose.  Further,  no 


FIG.  585. — Total  loss  of  nose  except  left  nla  and  columella. 

tendency  to  contraction  or  retraction  has  occurred  over  the  period  of  observation,  viz. 
eighteen  months :  at  times  the  nose  has  even  seemed  to  grow,  and  has  been  whittled  down 
into  its  existing  and  now  reasonable  proportions.  Again,  cartilaginous  support  for  this  nose 
was  inserted  at  a  late  stage,  i.e.  after  the  frontal  flap  was  in  position.  On  the  first  occasion, 
homologous  cartilage  was  used,  and  the  result  was  apparently  satisfactory  for  about 
fourteen  days,  when  the  nose  suddenly  swelled  up  and  about  a  teaspoonful  of  pus  was 
evacuated.  Three  days  later  no  more  suppuration  was  visible,  and  after  a  period  of  two 
months'  convalescence  there  was  no  sign  of  the  cartilage — it  had  obviously  been  absorbed. 
An  autokgous  cartilage  graft  was  later  inserted.  This  has,  at  the  time  of  writing, 
been  in  the  nose  five  months  and  is  obviously  permanent.  No  grafting  was  attempted  on 
the  forehead,  and  the  resultant  scar  is  by  no  means  offensive.  There  is  no  doubt  that,  by 
leaving  intact  the  skin  of  the  left  ala  and  columella.  the  blending  of  the  forehead  flap  with 


INJURIES    OF    THE    NOSE 


291 


this  skin  has  been  rendered  very  difficult,  and  one  feels  that  it  is  better  to  utilise  remaining 
pieces  of  skin  for  a  lining  membrane  or  to  excise  them. 

In  reviewing  this  case,  one  feels  the  correct  procedure  would  have  been  a  reflection  of 
the  surface  skin  over  the  left  ala  towards  the  right,  to  skin-line  that  portion  of  the  new  nose. 
The  flap  would  have  required  modification  to  include  the  left  ala  and  remains  of  the  tip, 
but  the  natural  form  of  this  nostril  would  still  have  been  kept  intact  by  the  supporting 
structure,  and  a  more  homogeneous  appearance  would  have  been  readily  obtained. 

The  following  are  the  details  of  the  case  : 

At  an  operation  performed  on  20.6.10  the  left  middle  turbinate  was  detached,  except 
at  anterior  end,  swung  forward  on  itself,  and  stitched  to  the  remains  of  the  septum  in  order 
to  build  up  the  bridge  of  the  nose  by  stages. 

On  9.8.16  the  right  inferior  turbinate  bone  was  removed  by  detaching  it  posterially 
as  far  as  its  anterior  end,  and  grafted  on  to  the  already  partly  formed  turbinate  septum, 
i.e.  superimposed  over  the  middle  turbinate  in  its  new  position. 

Under  local  anaesthetic,  the  anterior  attachment  of  the  right  inferior  turbinate,  which 
was  turned  up  in  previous  operations,  was  freed  and  sutured  to  the  remains  of  the  tip  of  the 
nose  to  form  a  bridge. 

A  rhinoplastic  (three-quarters  total)  operation  was  performed  on  11.10.16,  when  a 
celluloid  plate  was  first  placed  from  the  frontal  bone  to  the  tip  of  the  nose  over  the  existing 
turbinate  bridge  and  stitched  into  place.  A  flap  with  its  base  on  the  internal  angle  of  the 
right  eye  and  extending  obliquely  upwards  to  the  left  temple  was  cut  according  to  the 
accompanying  shape  and  dimensions — vide  diagrams.  It  was  twisted  down  and  sewn 
into  position.  The  right  ala  was  formed  by  curling  the  tip  of  this  flap  over  a  small  celluloid 
piece  stitched  to  the  tip  at  one  end  and  to  the  cheek  at  the  other.  No  seriovis  attempt 
was  made  to  close  the  frontal  wound.  A  relaxation  suture  from  the  flap  to  the  left  cheek 
was  inserted. 

On  28 . 10 . 16  the  frontal  flap  was  cut  through  at  level  of  eyebrow  and  also  at  attachment 
to  left  eyebrow  region,  and  the  pedicle  returned  to  the  forehead.  The  newly  cut  portion 


FlGS.  586  and  f>87.— Indian  rhinoplasty  over  celluloid  supports.     The  lining  was  provided  by  turbinate  grafts 
at  the  bridge  and  the  infolding  of  the  end  of  the  frontal  flap  at  the  vestibule 


292 


PLASTIC:  SURGERY 


of  the  flap  was  fitted  in  to  form  the  upper  part  of  the  bridge  of  the  nose.  In  joining  this 
to  the  skin  above,  the  nose  flap  was  made  to  lie  underneath  the  upper  skin  by  cutting  both 
very  diagonally.  Conversely,  the  skin  near  the  eyes  was  made  to  overlap  the  skin  of  the 
nose  by  similar  but  reverse  method.  The  nose  was  not  entirely  closed  on  the  left  side, 
and  this  necessitated  a  small  skin-flap  from  cheek  at  a  later  date. 

The  celluloid  splint  was  removed  from  nose  on  29.1.17. 

On  17.4.17  an  implantation  of  homologous  cartilage  was  performed.'  Two  lateral 
incisions  from  root  of  nose  up  over  frontal  region  were  made,  flap  of  periosteum  turned 
down,  and  bone  chiselled  upwards  forming  a  notch.  The  skin  was  separated  from  under- 
lying tissues  over  the  whole  length  of  dorsum,  rib  cartilage  inserted,  and  passed  through 
a  hole  in  periostea!  flap,  the  upper  end  of  cartilage  engaging  in  notch  of  bone  ;  a  small 
piece  of  cartilage  to  reinforce  left  ala.  A  small  flap  was  taken  from  the  left  cheek  to  relieve 
tension  when  suturing  in  this  region.  The  bulk  of  the  right  side  of  nose  was  reduced  by 
removing  an  elliptical  piece  of  skin  and  drawing  the  edges  together. 

A  further  operation  was  performed  on  18.9.17  for  implantation  of  autologous  cartilage 
into  bridge  of  nose.  The  cartilage  inserted  at  previous  operation  lias  become  entirely 
absorbed  and  the  nose  has  flattened.  The  cartilage  was  inserted  from  above  and  went  as 
far  as  the  tip.  The  support  of  the  cartilage  was  made  by  splitting  it  so  that  it  straddled 
the  deep  tissues.  Its  length  was  about  If  in.  An  attempt  was  also  made  to  make  an  ala 
on  the  right  side.  There  is  still,  however,  too  much  tissue  on  this  side.  Cartilage  taken 
from  the  seventh  right  rib. 

A  small  corrective  operation,  performed  later,  brought  this  rhinoplasty  to  its  present 
condition. 


Fio.  58S. — The  turbinate  grafts  complete, 
forming  support  and  mucous  membrane 
lining. 


Fio.  580. — The  celluloid  strips  Imd  to  be  removed 
and  this  globular  appearance  resulted. 


INJUKIES    OF    THE    NOSE 


293 


FIGS.  590,  591,  and  592. — After  autologous  cartilage  graft  to  bridge  and  trimming  of  right  ala.     The  forehead 

healed  by  granulation,  the  pedicle  being  returned. 


294 


PLASTIC    SURGERY 


CASE  132 

The  treatment  of  this  case  by  skin-grafting  the   intranasal  aspect   of  the   new   nose 
marks  a  definite  stage  in  the  advancement  of  rhinoplasty. 

The  injury  involved  complete  loss  of  nose  and  its  supports,  together  with  a  large  portion 
of  the  left  superior  maxilla.     The  appearance  on  admission  after  ten  days  was  that  of  a 

large  crater  in  the  middle   of  the   face   which   nor- 
mally was  filled  by  the  nose. 

When  the  tissues  had  become  healthy,  an  opera- 
tion was  undertaken  to  establish  and  maintain  the 
airway  ;  skin-grafts  were  applied  to  the  raw  areas 
after  the  intranasal  adhesions  were  freed.  This 
proved  a  satisfactory  procedure,  and  subsequent 
photographs  show  the  complete  freedom  of  the 
right  nasal  passage  from  stenosis. 

The  restoration  of  the  nose  was  then  designed, 
and  a  piece  of  cartilage  (the  shape  of  which  is  well 
seen  in  the  photographs  and  in  the  diagrams)  was 
inserted  through  an  incision  of  the  scalp  near  the 
hair-line.  This  cartilage  was  taken  from  the  eighth 
right  rib  and  was  3  in.  in  length  ;  it  was  split  along 
the  lower  border  and  the  two  halves  separated. 
Portions  of  it  were  then  removed  until  it  took  up 
the  shape  as  shown  in  Professor  Tonks's  diagram, 
fig.  594.  The  terminal  portion  of  the  cartilage  was 
pointed  and  extended  about  1  in.  from  where  the 
new  alae  joined  the  tip.  This  prolongation  was  for 
the  columella  support.  The  cartilage  had  a  ten- 
dency to  arch  somewhat,  and  this  columella  exten- 
sion of  the  cartilage  was  causing  a  little  pressure 
necrosis,  so  that  on  30.5.17  the  columella  was 
divided  with  a  tenotomy  knife  from  its  attachment 
to  the  tip,  and  a  small  portion  of  extruded  cartilage  at  the  extremity  of  the  cartilage 
was  cut  off.  The  wound  then  healed  without  further  trouble. 

The  next  stage  of  the  rhinoplasty  consisted  in  bringing  forward,  and  especially  to  the 
left,  portions  of  the  turbinates  and  septum,  so  that  there  should  be  a  satisfactory  bed  on 


1 


FIG.  593. — Total  loss  of  nose,  complicated 
by  lateral  maxillary  and  cheek  loss. 


A.  Portion  of  inferio- 
Turbinate  bone 
swung   across. 


Fio.  .504. — Shape  of  the  cartilage  and  the  position  into  which  it  was  put. 


INJURIES    OF    THE    NOSE 


295 


FIG.  595. — Shows  the  results  of  the  turbinate  and  septal  grafts 
helping  to  line  and  support  the  nose  laterally. 


which  to  implant  the  new  nose.     At  this  stage  a  colleague.  Major  Seccombe  Hett,  R.A.M.C., 

operated,  and  a  description  of  the  operations  is  given  in  the  following  paragraphs  : 

1.9.17. — Intranasal  operation    preparatory  to    plastic    operation    for   complete  new 

nose.     The  left  middle  turbinal  was  detached  from  its  connections  posteriorly  and  swung 

forward,  so  that  its  posterior  end 
was  brought  in  contact  with  and 
attached  to  the  anterior  end  of 
the  left  inferior  turbinal.  The 
right  inferior  turbinal  was  simi- 
larly treated,  and  its  posterior  end 
swung  up  and  attached  to  the 
root  of  the  nose.  The  cartila- 
ginous septum  was  detached  from 
the  floor  of  the  nose  and  also  from 
the  vomer.  remaining  attached  by 
a  pedicle  at  the  root  of  the  nose. 
It  was  rotated  and  placed  laterally, 
so  that  it  bridged  across  the  space 
between  the  right  inferior  turbinal 
and  the  left  middle,  to  both  of 
which  it  was  attached  by  cutgut 
suture. 
2.10.17. — Following  last  operation  there  is  now  a  mass  of  tissue  filling  up  the  cavity 

to  the  left  of  the  middle  line.     The  posterior  end  of  the  right  middle  turbinal  was  found  to 

be  firmly  attached  to  the  septum.     Its  anterior  attachment  was  now  separated  and  swung 

downwards  to  floor  of  the  nose  and  attached  there.     The  result  of  these  procedures  was 

that  a  very  considerable  gain  was  obtained,  as  is  very  evident  from  the  photograph,  fig.  595, 

which  shows  well  the  advance  turbinals  and  septum. 

There  still  remained  a  big  deficiency  of  the  left  maxilla,  which  one  decided  to  fill  up  with 

a  large  cheek-flap. 

Operation   (Major   Gillies). — The  skin 

and    scar    tissue   lying   beneath   the    left 

lower  lid  was  turned  in  towards  the  nose 

with  its  skin   surface   facing    backwards  ; 

the  eyelid  was  thus  freed  and  a  large  as- 
cending cheek-flap,  which  is  clearly  seen 

in     fig.    600,    was    swung    into    position. 

Thread   sutures   were   used   for  the  deep 

muscular  sutures,  a  supply  of  catgut  being 

temporarily  suspended,  and  these  thread 

sutures  gave  a  little  trouble,  as  they  tended 

to  work  out  through  the  scar.     No  general 

suppuration,  however,  occurred. 

At  the  same  operation,  one  decided  to 
cpithelialise  the  lower  half  of  the  nose 
while  it  was  still  in  situ  in  the  forehead. 
The  columella  and  alse  of  the  nose,  with 
imbedded  cartilage,  were  outlined  by  in- 
cision and  raised,  and  the  periosteum 
raised  for  some  distance  down  the  fore- 
head. An  impression  of  this  cavity  was 
then  made  in  Stent,  which  was  next  covered 
by  fresh  Thiersch  graft ;  it  was  reinserted 


FIG.  5!)f>. — View  from  above  forehead.  Skin-graft  on 
the  under  aspect  of  the  flap  and  on  skull.  Photo  taken 
on  the  eleventh  day  after  operation.  Note  :  the  graft 
was  so  perfect  that  it  could  be  picked  up  and  sutured 
to  the  skin  round  the  alao. 


29G 


PLASTIC    SURGERY 


and  the  skin  sewn  up.  A  little  suppuration  occurred,  and  when  the  Stent  was  removed 
on  the  tenth  day,  only  that  portion  of  the  grafting  which  lay  under  the  columella  had 
failed  to  take ;  all  the  rest  had  taken  in  a  most  remarkable  manner,  as  is  evidenced  by 
study  of  fig.  596.  The  epithelium  was  so  good  that  it  could  be  picked  up  with  forceps 
and  drawn  round  the  new  ala-  and  sewn  to  the  skin.  The  stitches  arc  in  evidence  in  the 
figure.  It  was  then  hoped  to  leave  the  nose  for  a  little  while,  but,  owing  to  obvious  re- 
traction and  thickening,  it  was  decided  to  swing  it  down  at  once.  The  further  outlining  of  the 
rhinoplastic  flap  was  undertaken  on  12.12.17,  and  followed  the  lines  indicated  in  fig.  597. 

The  lower  part  of  the  flap  had  been  epithelialised  by  the  inlay  ;  the  bridge  part  was 
lined  by  turning  in  small  flaps  from  over  the  glabella  and  left  cheek.  A  portion  of  the 
cartilage  was  exposed  and  excised  at  the  time  of  this  operation,  as  it  was  found  that 
after  the  inlay — and  perhaps  even  before  this  stage — the  cartilage,  probably  due  to  pressure, 
had  been  gradually  moving  its  position  and  coming  nearer  the  eyebrow.  This  manoeuvre 
of  exposing  the  imbedded  cartilage  and  excising  a  portion  of  it  without  prejudicing  the 
blood  supply  of  the  flap,  is  not  a  pleasant  experience  for  the  surgeon.  However,  in  this 


Fios.  597  and  598. — Diagrams  of  the  treatment  of  the  pedicle  and  forehead  deficiency  by  scalp  plastic. 

particular  case  no  infection  or  loss  of  blood  supply  occurred;  but,  in  view  of  Case  111  and 
others,  one  is  very  chary  of  interfering  with  the  imbedded  cartilage  until  it  has  been  well 
established  in  its  new  position.  Considerable  difficulty  occurred  in  getting  the  pedicle 
central  as  is  obvious  from  the  photograph,  fig.  600.  No  attempt  was  made  to  bend  the 
columella  which  had  become  very  thick  and  stiff,  and  it  was  also  found  impossible  to  gel 
the  frontal  flap  to  join  the  skin  of  the  cheek  near  the  left  ocular  angle.  The  already  thickened 
and  swollen  nose  became  larger,  but  under  the  influence  of  electro-therapeutic  measures. 
undertaken  by  Lieut.  H.  M.  Johnston,  this  nose  is  assuming  reasonable  proportions. 

Subsequent  treatment  consisted  in  the  return  of  the  pedicle  on  25.3. 18.     The  operation 

was  performed  under  novocaine  anaesthesia  three  months  later.     Also,  under  local  anesthesia. 

various  corrective  operations  were  performed  to  reduce  the  bulk  and  remedy  small  di- 

now  became  obvious  that  the  Thiersch  on  the  forehead,  which  had  been 

1  on  the  bone  by  the  Esser-Inlay  method,  was  remaining  depressed  and  fixed  firmly 

:  bone      A  plastic  operation  for  its  excision  was  carried  out  under  general  anaesthesia 

and  the  scalp  advanced  to  fill  up  the  gap. 

Details  and  diagrams  of  this  operation  are  appended  : 

19.7.18.  Operation.— Under  general  anaesthesia.  Object  to  remove  large  depressed 
skill-grafted  area  on  forehead  and  raise  eyebrow,  etc. 


INJURIES    OF    THE    NOSE 


297 


FIG.  599. — Profile  showing  the 
cartilage  in  forehead. 


FIG.   600. — The  early,  very  thickened,  result. 
Note  the  skin-graft  on  forehead. 


FIG.  601. — Profile  of  same  stage. 
The  columella  was  so  swollen  that 
it  could  not  be  bent  into  position. 


FIGS.  602  and  603. — Result  of  the  treatment. 


•298 


PLASTIC    SURGERY 


Long  incision  from  right  eyebrow  to  top  limit  of  forehead  scar  followed  by  the  excision 
of  the  remains  of  the  skin-graft  and  sear  tissue.  The  right  eyebrow  could  now  be  lifted  to 
its  normal  level.  In  order  to  get  an  easy  closure  of  the  forehead,  an  advancing  flap  from 
the  temporal  region  of  the  scalp  was  swung  down  to  complete  the  forehead.  Further 
plastic  adjustments  at  the  root  of  the  nose,  combined  with  an  excision  of  part  of  the  imbedded 
cartilage,  produced  a  very  much  more  satisfactory  result  in  the  glabellar  region.  A  deep 
catgut  suture  from  the  tissue  overlying  the  cartilage  to  the  periosteum  of  the  glabellar 
region  gave  a  hitch  to  his  nose  which  lifted  the  tip  and  columclla  into  a  very  satisfactory 
position.  It  was  not  expected,  however,  that  the  elevation  of  this  would  remain  so  marked 
owing  to  the  attachment  of  the  nose  to  the  left  cheek. 

1.8.18.  Progress. — Satisfactory.  Slight  dropping  of  tip  noticed.  The  total  result 
to  date  is  sufficiently  satisfactory,  and  is  probably  capable  of  much  improvement. 


FIGS.  604,  COS,  and  600. — Shortly  after  final  corrective  operation. 


INJURIES  IN  THE  REGION  OF  THE  EYES, 
INCLUDING  BURNS  OF  THE  FACE,  AND 
INJURIES  TO  THE  PINNA 


CHAPTER  VII 

INJURIES    IN    THE    REGION    OF    THE    EYES,    INCLUDING 

BURNS   OF   THE   FACE 

THIS  section  includes  not  only  description  of  injuries  of  the  orbital  ring,  of 
the  eyelids  and  the  sockets,  but,  in  addition,  the  operative  treatment  of  burns. 
The  most  important  and  outstanding  result  of  severe  facial  burns  is  ectropion 
of  the  eyelids.  It  was  found  impracticable  to  devote  a  separate  chapter  to 
burns  for  this  reason.  The  palliative  treatment  of  paralysis  of  the  eyelid  muscles 
and  the  principles  of  otoplasty  are  also  discussed. 

For  convenience  of  discussion  injuries  of  the  eye  region  are  subdivided 
into— 

1.  INJURIES  OF  THE  ORBITAL  RING. 

2.  INJURIES  OF  THE  EYELIDS. 

3.  INJURIES  OF  THE  SOCKET. 

In  a  subsection  of  this   chapter — Burns   of  the  Face — plastic  operations 
on  the  pinna  are  discussed. 


300 


INJURIES   IN   THE   REGION   OF   THE   EYES  301 


INJURIES    OF    THE    ORBITAL    RING 

Many  gunshot  injuries  result  in  loss  of  the  superciliary  ridge  of  the  frontal 
bone,  the  external  angular  process,  the  malar  bone,  and  the  infra-orbital  plate. 
With  these  bony  losses  of  the  orbital  borders  are  frequently  associated  losses 
of  the  lids  and  damage  to  the  eye  and  socket ;  but  in  the  following  cases  I  have 
limited  the  examples  to  those  in  which  the  repair  is  mainly  centred  in  replace- 
ment of  the  bony  contour.  These  are  among  the  most  satisfactory  of  the 
plastic  restorations  of  the  face,  and,  provided  the  eye-socket  is  clean,  there  is 
little  risk  of  infective  troubles.  However,  when  the  injury  involves  the  frontal 
sinuses,  care  must  be  taken  that  the  graft  restoring  the  shape  does  not  lie  in 
connection  with  the  mucous  cavity.  The  restorations  have  been  made  mostly 
by  the  aid  of  shaped  cartilage  implantations,  and  almost  perfect  restoration 
of  contour  has  thereby  been  obtained. 

When  a  larger  loss  of  bone  occurs,  constituting  a  cranial  defect,  the  cranial 
cavity  may  be  shut  off  by  an  osteoperiosteal  graft — which  I  have  not  personally 
used — or  by  an  extension  of  the  cartilage  restoration.  It  is  advisable  to  work 
out,  with  the  aid  of  the  sculptor,  the  exact  amount  and  shape  of  the  loss,  and 
to  make  a  metallic  model  of  the  necessary  implantation  before  the  operation. 
This  enables  one  to  shape  the  cartilage  exactly  at  the  time  of  operation. 

Frequently  it  is  necessary  to  replace  the  eyebrow.  The  loss  of  the  eyebrow 
hair  is  a  serious  defect,  which  may  be  corrected  by  the  wearing  of  artificial 
eyebrows  or  tattooing  of  the  skin—  a  quite  useful  camouflage.  Surgical  repair 
is  illustrated  by  two  cases.  In  one,  a  whole-thickness  free  graft  from  the  hairy 
scalp  over  the  mastoid,  and,  in  the  other,  a  pedicle  flap  carrying  hair  from  the 
scalp  region  is  grafted  into  position.  Care  must  be  exercised  to  choose  a  part 
in  which  the  hairs  are  growing  in  the  right  direction. 

For  the  external  angular  process  cartilage  is  indicated,  while  for  the  loss 
of  the  malar  the  author's  temporal  muscle-flap  is  very  satisfactory  in  some 
cases,  and  in  others  serves  as  an  excellent  basis  for  the  addition  of  a  cartilage 
graft.  Loss  of  the  orbital  plate  of  the  maxilla,  resulting  in  a  downward  dis- 
placement of  the  globe  and  socket,  is  remedied  by  cartilaginous  implantation, 
sometimes  from  the  rib,  and  sometimes  from  the  helix  or  antihelix  of  the  pinna. 


302 


PLASTIC   SURGERY 


CASE  307 

This  sergeant  received  a  shell-wound  in  the  right  temporal  region,  eausing  loss  of  the 
outer  portion  of  the  superciliary  margin  of  the  frontal  bone.  The  healed  condition  is  repre- 
sented by  a  depressed  scar  which  includes  the  lateral  portion  of  the  eyebrow.  The  scar 
was  first  excised  and  the  level  of  the  eyebrow  corrected.  A  small  flap  of  temporal  muscle 
was  dissected  and  laid  in  the  line  of  the  wound  to  restore  the  contour.  The  result  was  good, 
excepting  a  distinct  depression  of  contour,  which  was  remedied  later  by  cartilage  graft.  At 
the  same  time,  a  cartilage  globe  was  inserted  into  the  socket  to  relieve  the  sunken  condition 
of  the  lids.  This  cartilage  globe  operation  is  described  under  the  subsection  on  sockets. 

Operation  Notes : 

12.7.17.  Operation. — For  the  formation  of  the  right  superciliary  margin  and  for 
excision  of  scar.  Scar  was  excised.  As  a  small  amount  of  muco-pus  appeared  on  the  lower 
part  of  the  wound  it  was  decided  not  to  graft  any  cartilage.  In  order  to  make  contour, 
incision  was  prolonged  downwards  towards  the  temporal  region,  and  flap  of  muscle  was 
outlined  and  swung  upwards  from  its  origin  and  stitched  to  the  subcutaneous  tissue  of  the 
eyebrow.  In  order  to  get  the  eyebrow  into  line,  it  was  necessary  to  put  in  a  relaxation 
suture  with  plate.  Wound  edge  closed  with  thread  ;  drainage  provided  by  silk-worm  gut 
at  each  end. 

27.10.17.— Result  of  previous  operation  satisfactory.  Slight  depression  of  super- 
ciliary ridge.  Eye  socket  sunken. 

27.10.17.   Operation. — Insertion  of  cartilage  globe  and  cartilage  into  eyebrow. 

Cartilage  sphere  operation  as  usual.  The  cartilage  being  in  one  ovoid  piece.  Small 
strip  inserted  through  small  incision  in  right  temporal  region  to  complete  superciliary  ridge. 


Fid.  607. — Excision  of  scar,  adjustment  of  eyebrow, 
and  muscle  swing  to  help  fill  depression. 


Fia.  008. — Suture. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


303 


FIG.  609.— Healed  condition  :  Outer  part  of  eyebrow  raised  by  soar,  and  loss  of  bony  prominence. 


Front  view.  Semi-profile  view. 

Fios.  610  and  Gil. — After  excision  of  scar  and  cartilage  graft. 


304  PLASTIC    SURGERY 

CASE  558a 

A  severe  gunshot  injury  carried  away  a  large  portion  of  the  frontal  bone  and  the  eye- 
brow. The  eye  had  been  destroyed  or  removed  prior  to  this  patient's  admission.  In 
addition  to  the  destruction  of  all  the  superciliary  margin,  there  was  a  cranial  defect  of  about 
the  size  of  a  florin.  The  main  scar  ran  along  the  centre  of  a  depression  from  the  inner  edge 
of  the  ridge  to  the  external  angular  process,  which  was  also  partly  destroyed. 

The  interest  of  this  restoration  centres  in  an  accident  which  happened  to  the  cartilage 
graft  and  in  the  lesson  it  taught.  A  very  exact  estimation  of  the  amount  of  cartilage  to 
restore  the  contour  was  first  made  and  the  model  cut  into  two  pieces,  so  that  it  could  be 
reproduced  from  adjacent  ribs.  The  cartilage  was  shaped  satisfactorily  and  inserted  through 
the  end  of  the  scar  over  the  external  angular  process.  The  rest  of  the  scar  and  skin  was 
elevated  by  undercutting  until  it  could  be  stretched  forward  to  contain  the  cartilage. 

A  very  perfect  restoration  was  the  result.  Hasmatoma  and  infection  followed,  however, 
and  owing  to  the  exposure  of  the  dura  mater,  it  was  expedient  to  remove  the  cartilage  and 
avoid  possible  risk  of  meningitis. 

There  is  no  doubt  that  (1)  a  preliminary  plastic  should  have  been  done  to  reduce  the 
scar  and  to  provide  more  lax  healthy  skin  to  nourish  the  cartilage  ;  (2)  there  is  always  a 
certain  amount  of  danger  of  haematoma  in  these  undercutting  operations  done  through  a 
small  incision,  and  a  more  open  type  of  operation  is  better. 

This  infection  of  the  cartilage  was  the  first  accident.  It  was  decided  to  boil  this  care- 
fully shaped  graft  for  five  minutes,  after  which  it  was  inserted  subcutancously  over  the 
abdomen,  where  the  implantation  wound  healed  satisfactorily.  A  piece  of  this  was  retained 
for  histological  examination.  It  should  be  noted  that  a  cartilage  globe  was  inserted  at 
the  back  of  the  left  eye  socket,  which  was  entirely  satisfactory. 

After  due  interval  a  plastic  was  performed  on  the  forehead  for  excision  of  the  dense  scar 
and  for  advancement  in  a  downward  direction  of  the  forehead  and  scalp,  so  that  more 
skin  was  brought  into  the  eyebrow  region.  This  having  healed  satisfactorily,  the  original 
shaped  cartilage  was  removed  from  the  abdominal  wall,  and  a  bed  made  for  its  reinsertion 
into  the  forehead.  It  was  observed  that  the  cartilage  had  the  same  appearance  in  shape 
as  when  it  had  been  last  seen  some  nine  months  previously. 

While  the  bed  was  being  made  for  it,  the  cartilage  was  laid  in  a  swab  on  the  instrument- 
table,  and  its  second  accident  then  occurred.  One  of  the  attendant  "  scavengers  "  of  the 
theatre  zealously  removed,  with  sterile  forceps,  what  was  considered  to  be  a  dirty  swab, 
and  the  precious  cartilage  found  its  way  to  an  unsterile  bucket.  It  seemed  probable  that 
the  cartilage  had  touched  nothing  unsterile,  hence  it  was  removed  from  the  bucket  and, 
without  further  incident,  was  inserted  in  its  bed.  No  further  untoward  symptoms  have 
occurred.  There  remains  the  provision  of  an  eyebrow  to  complete  the  case. 

Operation  notes  : 

23.5.18.  Operation. — Method  of  treatment.  The  necessary  amount  of  cartilage  to 
restore  the  contour  was  accurately  gauged  on  a  plaster  cast,  and  a  composition  model  thereof 
made  in  two  sections  by  Major  Dorrance,  M.R.C.  The  two  halves  were  made  so  that  they 
could  be  reproduced  from  ordinary  rib  cartilage. 

(1)  Incision  made  above  remains  of  eyebrow  at  outer  angle  and  also  above  depression 
at  inner  side.     From  these  two  incisions  the  skin  was  undercut,  care  being  taken  not  to 
wound  the  dura  mater.     This  elevation  of  the  skin  was  tedious.     Cartilage  was  taken  from 
right  thorax,  shaped  by  Major  Dorrance  to  pattern.     These  were  slipped  in  through  the 
outer  incision,  producing  a  perfect  restoration  of  contour. 

(2)  A  globe  of  cartilage  was  inserted  through  the  conjunctiva  in  the  usual  manner  into 
left  socket. 

Result. — Hacmatoma  occurred  in  forehead,  followed  by  temperature  and  pain.  Owing 
to  the  proximity  of  the  dura  mater  and  the  continuance  of  slight  temperature  the  cartilage 
was  removed  (27th)  under  general  anaesthesia. 

The  surface  of  the  cartilage  in  two  or  three  places  was  covered  with  lymph,  showing 
early  infection,  and  culture  showed  presence  of  streptococci.  A  small  portion  of  infected 


INJURIES   IN   THE   REGION   OF   THE   EYES 


305 


cartilage  for  section  was  "sent  to  Professor  Keith. 
The  rest  of  the  cartilage  was  boiled  for  five  minutes 
and  reinserted  into  abdominal  wall.  Subsequent 
progress  satisfactory.  Cartilage  remains  same  size 
and  shape  to  date — 1.7.18 — no  absorption  having 
yet  occurred. 

9.9.18. — The  cartilage  graft  in  the  abdominal 
wall  appears  satisfactory  and  undiminished. 

9.9.18.  Operation. — It  was  decided,  in  order 
to  make  a  good  bed  for  the  cartilage,  to  advance 
the  scalp  to  bring  sufficient  skin  into  superciliary 
region.  The  scar  tissue  was  freely  excised  in  this 
area,  and  from  the  inner  extremity  of  this  incision 
the  knife  was  carried  up  over  the  forehead  and  scalp 
for  a  distance  of  two  inches  from  the  hair-line.  An 
abrupt  "  V  "  was  then  made  to  the  left,  and  the 
knife  carried  down  as  far  as  the  left  temporal 
region.  This  enabled  the  whole  of  the  forehead  to 
be  suitably  advanced.  Closure  resulted  in  a  "  Y  ' 
suture. 

Note. — The  dura  mater  was  not  exposed  during 
this  operation.  Primary  healing. 

12.1.19.  Operation. — Under  general  anaesthesia 
the  cartilage  in  the  abdominal  wall  was  removed. 

(It  should  be  noted  that  the  graft  appeared 
much  the  same  in  shape  and  character  as  when  it 
had  been  inserted  after  boiling  on  the  occasion  of 
the  second  operation.  Piece  taken  for  section.) 

A   flap   was  next  turned  up   by  long  incision  extending  across   the   whole  area,  so 
that  free  inspection  of  the  bed  could  be  made.     Cartilage  inserted  and  skin  sewn  up. 

24.2.19.   Result. — Restoration  appears  quite  satisfactory,  and  no  rise  of  temperature 
occurred.     A  slight  deficiency  in  the  contour  is  noticeable  in  the  middle  of  the  area. 


Fio.  012. — Cast  of  healed  condition,  showing 
loss  of  superciliary  margin. 


FIG.  613. — After  second  plastic  in  which  forehead 
skin  was  advanced  to  provide  a  good  bed  for  the 
cartilage  graft. 

20 


FIG.  614. — Final  ;  Contour  improved. 


306  PLASTIC   SURGERY 


CASE  929 

This  officer  patient  shows  a  very  similar  injury  to  the  previous  case,  but  the  scar  is 
well  up  on  the  forehead  and  the  eyebrow  is  intact.  A  larger  cranial  defect  is  present  through 
which  the  pulsating  dura  mater  is  plainly  visible,  and  the  external  angular  process  has 
also  been  shot  away,  together  with  a  portion  of  the  malar  region.  The  socket  holds  an 
artificial  eye,  but  this  eye  is  turned  latcralwards.  Another  feature  about  the  cranial  defect 
is  that  the  depression  is  very  considerably  diminished  when  the  brain  is  under  higher  pres- 
sure ;  the  two  plaster  casts  illustrated  show  this  difference  in  contour,  due  to  differences 
of  the  intra-eranial  pressure.  The  first  stage  of  the  reconstruction  has  been  carried  out 
by  implantation  of  cartilage  graft  from  adjacent  ribs.  The  scar  on  the  top  of  the  forehead 
was  utilised  for  the  incision  of  a  flap  which  provided  a  clear  view  of  the  operation  area. 
A  little  more  of  the  external  orbital  ring  remains  to  be  built  up  by  the  aid  of  spare  cartilage, 
which  was  taken  at  the  time. 

27.1.19.  Operation. — General  anaesthesia.  Incision  over  the  right  rectus  and  ex- 
posure of  the  cartilage  area.  The  attached  adjacent  portions  of  ribs  7  and  8  were  removed — 
also  a  spare  piece.  Wound  closed  and  spare  piece  inserted  subcutaneously.  Two  joined 
cartilages  were  properly  shaped.  Incision  over  the  left  forehead  along  the  line  of 
the  scar,  curved  downwards  at  each  end  so  that  full  exposure  could  be  obtained.  The 
skin  was  very  carefully  undercut,  so  as  to  avoid  wounding  the  dura  mater,  which  was  closely 
adherent.  The  flap  was  turned  down  and  all  bleeding  points  stopped.  Cartilage  inserted, 
and  sewn  down  by  cutgut  to  the  periosteum  at  each  end  and  the  wound  closed. 

Result.— Wounds  healed  by  first  intention. 

Complication. — Influenza  developed  third  day. 


FIG.  015. — On  admission. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


307 


FIG.   016. — Cast  taken  while  intra-cranial 
pressure  was  raised. 


FIG.  617. — Cast  while  intra-cranial 
pressure  was  low. 


FIGS.  618  and  619. — After  cartilage  implantation. 


308 


PLASTIC  SURGERY 


CASE  75 

In  this  injury  the  loss  of  the  bone  is  considerably  loss  and  there  is  no  cranial  defect, 
but  the  eyebrow  lias  been  destroyed  over  its  outer  two-thirds,  its  place  being  taken  by  a 
dense  scar  which  also  runs  across  the  external  angular  process  to  the  cheek.  The  left  eye 
socket,  which  was  carrying  an  artificial  eye,  is  considerably  depressed. 


FIG    620. — Temporal  flap  outlined. 


FIG.  621.— Suture. 


The  reconstruction  of  the  eyebrow  was  first 
attempted  by  use  of  a  flap,  which  is  seen  in  the 
diagram.  It  was  cut  from  the  left  temporal 
region,  where  the  hair  grows  in  the  requisite 
direction.  Fig.  623  shows  the  bridge  pedicle 
flap  in  position ;  this  was  not  tubed.  Uoth 
the  flap  operation  and  the  return  of  the  pedicle 
were  performed  under  local  anaesthesia  (infiltra- 
tion— Kerocain). 

The  further  stage  of  this  case  will  include 
the  raising  of  the  socket  by  cartilaginous  im- 
plantation, for  which  the  spare  pieces  were 
taken. 


l-'i'i.  (>ii. — Healed  condition  (scalp  prepared 
tor  operation).  Outt.-  two-thirds  left  eyebrow 
missing. 


INJURIES   IN   THE   RECxION   OF   THE   EYES 


309 


FIG.  623. — Bridge-pedicle  temporal  flap  in  position. 


FIG.  624. — Pedicle  returned. 


FIG.  025. — To   show   minimal    disfigurement   by 
pedicle  scar. 


FIG.   020. — After  cartilage  implant  to  malar  region. 


310  PLASTIC   SURGERY 

CASE  518 

This  case  is  unfinished,  but  is  of  considerable  interest  because  of  the  eye  socket.  The 
original  picture,  fig.  627,  shows  that  the  whole  of  the  malar  and  a  very  large  portion  of  the 
upper  part  of  the  left  superior  maxilla  have  been  destroyed. 

The  large  gap  in  the  cheek  contour  has  been  remedied,  to  a  very  great  extent,  by  a 
temporal  muscle-flap,  while  the  necessary  skin  has  been  brought  down  from  the  left  temple 
region.  Although  the  socket  is  not  yet  up  to  a  normal  level,  a  most  satisfactory  improvement 
has  been  effected. 

At  this  officer's  own  request,  his  final  treatment  has  been  deferred  for  two  or  three 
years.  It  will  probably  consist  in  the  reconstruction  of  the  nose  and  the  support  of  the 
left  eye  socket  by  cartilage  implantation. 

Operation  notes  : 

21.3.18.  Operation. — Restoration  of  remains  of  nose  to  normal  position.  Complete 
separation  was  made  between  the  remains  of  the  cheek  and  the  nose  on  the  left  side.  The 
alsc  were  freed  of  their  attachments  and  the  nose  elevated,  retained  by  a  head-nose  ap- 
paratus (Captain  Fry). 

An  effort  was  also  made  to  raise  the  bridge  of  the  nose  by  an  osteotomy  of  the  right 
nasal  process  through  a  separate  incision.  Nasal  passages  were  partly  re-established. 

21.4.18.  Progress. — Head -gear  discarded  and  lateral  spring  apparatus  fitted  (Captain 
Fry). 

20.7.18.- — The  parts  of  the  nose  remaining  are  in  good  position,  with  tip  depressed. 

20.7.18.   Operation. — Plastic  on  nose,  replacement  of  eyelids,  filling  in  cheek  depression. 

Remains  of  left  ala,  which  was  attached  to  the  nose,  was  divided  from  above  downwards, 
about  f  in.  turned  downwards  and  outwards.  Triangular  flap,  with  its  base  at  the  margin 
of  the  nasal  fossa — approximately  1  in.  x  l£  in. — was  elevated  from  the  cheek  and  sown 
to  the  nose  to  make  the  inner  lining.  It  consisted  of  skin  with  a  good  many  scars.  The 
previously  detached  ala  was  sutured  to  the  anterior  margin  of  this  and  to  a  raw  area  on 
the  upper  lip. 

A  semicircular  incision  extending  from  £  in.  above  and  to  the  inner  side  of  the  inner 
canthus  downwards  and  outwards  on  the  line  of  an  old  scar  to  a  point  an  inch  external  to 
the  external  canthus. 

The  upper  and  lower  flaps  were  elevated,  leaving  a  depressed  area  approximately  1|  in. 
in  width. 

The  lower  eyelid  was  now  sutured  to  the  inner  end  of  the  above  described  incision,  in 
this  way  returning  the  eyelid  to  more  normal  position. 

A  skin-flap  was  now  elevated  from  the  left  frontal  and  temporal  regions,  with  its  base 
extending  forward  for  1|  in.  from  the  upper  margin  of  the  left  ear.  This  flap  Avas  long 
enough,  when  reflected,  to  reach  the  side  of  the  nose  and  cover  the  exposed  area  below  the 
eye.  This  flap  contained  the  temporal  artery.  The  anterior  half  of  the  temporal  muscle 
was  now  elevated  from  its  fossa,  the  superimposed  fascia  divided  where  it  was  originally 
attached  to  the  zygoma.  A  tunnel  was  now  established  beneath  the  scar  tissue,  which 
represented  the  original  position  of  the  zygoma,  and  the  muscle  was  drawn  through  this 
tunnel  to  fill  completely  the  depression  under  the  eye.  The  temporal  muscle  was  then 
sutured  over  this  muscle  to  the  margin  of  the  skin.  The  skin  margins  of  the  frontal  and 
temporal  regions  were  undermined  and  approximated  in  the  frontal  area.  The  temporal 
area  will  be  filled  by  return  of  pedicle.  Operative  result  very  satisfactory. 

5.11.18.   Operation. — Return  of  pedicle  to  temporal  region  (local  anaesthetic). 

6.12.18.  Operation. — Excision  of  scar,  together  with  a  small  plastic  on  the  left  ala 
in  order  to  improve  the  airway. 

Patient  now  wishes  to  return  to  civil  life.  The  cartilage  to  nose  and  lower  eyelid  have 
therefore  been  postponed.  Rest  of  cheek  plastics  very  satisfactory,  the  very  large  depression 
having  been  completely  filled. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


311 


FIG.  627. — Healed  condition  :  Loss  of  prominence  of  infra-orbital  margin, 
distortion  of  nose  and  stenosis  left  naris,  malposition  left  lower  lid. 


Fio.  628. — Infra-orbital  depression  almost  overcome  by  temporal  flap.      Xose  straightened  and 
naris  remade.     Lower  lid  replaced.     Case  unfinished  :  for  cartilage  implants  later. 


312 


PLASTIC    SURGERY 


CASE  40 

This  case  has  been  illustrated  in  the  section  on  cheeks,  and  shows  loss  of  the  orbital 
ring  through  depression  of  the  malar,  together  with  dragging  downwards  and  outwards 
of  the  outer  canthus.  It  is  cured  by  the  author's  temporal  muscle-flap,  for  details  of 
which  see  Section  on  Cheeks,  Case  40,  p.  54. 


l«'ic.  (129. — Depression  in  malar  region. 


Fia.  630. — Depression  relieved  by  temporal  muscle  swing. 


INJURIES   IN  THE   REGION   OF   THE   EYES  313 


INFERIOR    BLEPHAROPLASTY 

The  following  seven  cases  show  more  or  less  severe  injuries  of  the  lower 
lid,  with  loss  of  the  lower  lid  and  traumatic  cctropion. 

Where  the  loss  of  the  lid-edge  is  one-third  or  less,  a  very  satisfactory  repair 
can  be  made,  but  where  the  whole  lid  has  been  destroyed  the  operation  results 
seen  by  the  author  are  considerably  wanting  in  finish. 

Of  the  various  methods  of  blepharoplasty  used  by  ophthalmic  surgeons 
after  tumour  removals,  however,  few  seem  to  have  recognised  the  principle 
of  providing  all  the  elements  of  the  lid — that  is  to  say,  lining  membrane,  support, 
and  skin  covering.  Mellor  (Vienna)  uses  free  transplants  of  skin  and  cartilage 
from  the  ear,  which  are  attached  to  the  back  of  the  external  flap.  Pro- 
vided the  graft  takes,  this  should  give  an  excellent  result.  Eversbusch  has 
used  a  pedunculated  flap,  which  is  previously  skin-grafted  before  being  brought 
into  position  to  form  part  of  a  lid.  But  the  other  standard  operations  for 
blepharoplasty  would  not  appear  to  have  embodied  the  principle  of  providing 
an  epithelial  lining.  The  author  wishes  to  point  out  that  he  has  had  little 
experience  of  reforming  lids  when  a  functional  eye  is  present,  and  the  majority 
of  the  cases  under  construction  arc  those  in  which  the  eye  has  been  destroyed 
or  removed.  Consequently,  the  value  or  harm  of  the  presence  of  a  skin  surface 
towards  the  cornea  cannot  be  discussed ;  but,  when  the  socket  is  empty,  the 
author  is  strongly  of  the  opinion  that  all  three  elements  of  the  lid  should  be 
embodied  in  the  reconstruction.  Just  as  in  rhinoplasty,  skin  lining,  cartilage 
support  and  skin  covering  were  found  to  be  essential  both  for  preservation 
of  form  and  function.  So  in  the  lid  the  best  results  are  obtained  when  this 
principle  is  carried  out.  The  method  preferred  is  that  illustrated  in  the  diagrams 
attached,  and  it  is  exactly  comparable  with  the  author's  skin  cartilage  swing 
which  has  been  so  satisfactory  with  the  nose. 

The  operation  is  divided  into  two  stages.  In  the  first  stage,  cartilage, 
either  from  the  ear  or  from  the  ribs,  of  a  suitable  length  and  thickness,  is  inserted 
beneath  a  flap  extending  outwards  from  the  outer  canthus.  When  the  cartilage 
has  received  its  new  blood  supply  the  combined  skin- cartilage  flap  is  raised 
and  swung  in  on  a  hinge  near  the  canthus.  The  skin  comes  to  form  the  lining 
of  the  new  lower  .lid  and  the  cartilage  is  now  on  its  anterior  aspect,  and  the 
lower  border  of  the  skin  flap  is  carefully  sutured  to  the  remains  of  the  conjunctiva 
to  complete  the  socket.  There  is  now  a  raw  area  double  the  size  of  the  flap, 
and  it  may  be  dealt  with  in  the  following  ways  : 

(a)  The  cheek  wound  may  be  closed  by  approximation  and  the  lid  portion 
Thiersch-grafted. 


PLASTIC   SURGERY 

(b)  A  descending  temporal  skin- flap    may  be  swung  down  to  cover  both 

defects. 

(c)  An  ascending  flap  may  be  brought  up  from  the  cheek. 

(d)  A  double  pedicle  flap  may  be  taken  from  the  upper  lid  (Tripier) ;    or 

(e)  The  skin  may  be  conveyed  to  the  lid  by  a  tube-pedicle  from  the  neck 

(author's  principle). 

When  an  eyelid  repair  is  carried  out  at  the  same  time  as  a  rhinoplasty 
an  additional  piece  can  be  added  to  the  rhinoplastic  flap  to  provide  the  necessary 
skin  for  the  lid. 

In  regard  to  the  skin-grafting  methods  for  lids,  no  advantage  over  the 
Thiersch  graft  would  appear  to  result  from  the  use  of  Wolfe  graft.  Where 
there  is  no  other  deformity  in  the  neighbourhood  of  the  lid  the  skin-grafting 
method  produces  least  additional  scar. 


Fid.  631.— Flap  partly  outlined. 


Fia.  632.— Cartilage  being  implanted. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


315 


FIG.  033. — End  of  first  stage. 


Fra.  634.— Cartilage-bearing  flap  outlined. 


FIG.  635. — Lining  and  support  provided. 


FIG.  636. — Skin  covering  by  free  graft. 


o 


FIG.  637. — Skin  covering  by  flap. 


FIG.  638. — Suture. 


816 


PLASTIC   SURGERY 
INJURIES    OF    THE    EYELIDS 


Tim  r  rases  arc  shown  in  this  group  to  illustrate  the  attempted  replacement 
of  distorted  eyelids. 

CASE  699A 

Severe  injury  lias  occurred  to  the  left  eye  socket  and  region  of  the  frontal  sinuses. 
Cranial  defect  was  present,  and  pulsation  could  be  felt  on  the  inner1  wall  of  the  left  orbit. 

It  is  difficult  to  conceive  how  the  upper  lid  had  become  adherent  at  such  a  low  level. 
A  considerable  portion  of  the  lower  lid  edge  was  still  present,  concealed  in  a  pocket  beneath 
the  upper  lid. 

An  incision  was  made  for  raising  the  upper  lid,  and  a  flap — including  the  remains  of 
the  lower  lid — was  swung  upwards  and  inwards  from  the  cheek.  Cartilage  was  taken 
from  the  right  costal  region,  and  imbedded  for  future  use.  Some  will  be  used  to  cure  the 
glabellar  depression,  while  further  support  to  the  socket  and  lower  lid  will  be  furnished  by 
the  remainder.  Hchind  the  new  lower  lid  an  epithelial  inlay  (Esser)  has  been  carried  out, 
and  a  picture,  fig.  640,  shows,  in  position,  the  vulcanite  retention  apparatus  to  prevent 
the  graft  from  shrinking  until  the  artificial  eye  is  fitted. 

Operation  notes : 

10.9. 18.  Operation. — Incision  made  from  the  inner  end  of  left  eyebrow  to  the  attached 
inner  end  of  the  upper  eyelid,  so  that  this  could  be  completely  freed  and  sewn  at  a  higher 
level.  The  socket  was  completed  by  excising  adherent  scars  and  swinging  a  flap  to 
lower  lid.  Cartilage  from  costal  wall  was  taken  to  aid  in  the  reconstruction  of  the  various 
depressions  and  imbedded  in  abdominal  wall. 

Kesult.—  Satisfactory.     Wound  healed  by  first  intention. 

Complications. — Acute  lobar  pneumonia.     Recovery. 

20.12.18.— Epithelial  graft  to  left  lower  lid. 


l-'l'i.  ''''lit.       OIL    M.lmijMioil. 


Fio.  040.— After  lid  plastic  :    Vulcanite  in  socket 
to  control  Tliiorsch  graft  lining  lower  lid. 


INJURIES   IN   THE   REGION   OF   THE   EYES 

CASE  43 


317 


This  case  has  been  described  under  "  upper  lips,"  but  this  patient  also  had  derangement 
of  the  left  upper  lid,  which  was  adherent  at  a  level  lower  than  the  lower  lid.  The  inner 
canthus  was  also  displaced,  downwards  and  outwards.  By  means  of  the  Z  incision,  shown 
on  the  diagram,  fig.  642,  the  upper  lid  and  the  inner  canthus  were  replaced  in  nearly  normal 
position. 


FIG.  641. — Healed  condition 


FIG.  042. — Incision. 


FIG.  043. — After  plastic  to  lid. 


318 


PLASTIC   SURGERY 


CASE  318 

The  third  case  shows  a  more  severe  injury  of  the  malar  and  infra-orbital  region,  which 
resulted  in  considerable  displacement  outwards  and  downwards  of  the  lower  lid. 

The  main  restorative  operation  consisted  of  excision  of  scar,  the  bringing  down  of  a 
temporal  muscle  flap,  and  suture  of  cheek-flaps  over  this  muscle  transplant. 

Tliis  procedure  reduced  the  case  to  one  of  ectropion.  The  lid  was  really  more  drawn 
away  from  the  socket  than  everted.  A  cartilage  rod  was  fitted  in  subcutaneously  along  the 
lower  lid.  It  effected  a  very  considerable  improvement,  both  in  raising  in  the  lid  and  in 
approximating  the  conjunctival  surfaces.  There  was  still,  however,  an  imperfect  apposition. 

6.9.17.  Operation. — Loss  of  superior  maxilla,  orbital  plate,  and  part  of  malar  and 
lower  lid.  Large  scar  had  to  be  excised  first.  Two  cheek-flaps  were  outlined  for  the  skin 
covering  (see  fig.  645),  shaped  temporal  flap  turned  down,  and  the  anterior  portion  of 
muscle  was  swung  forward  over  the  remains  of  the  malar-bone  and  sutured  under  the  eye. 
The  wound  was  closed  in  the  usual  manner,  and  a  long  relaxation  suture  was  passed  to  the 
eyebrow. 

The  result  is  not  likely  to  be  more  than  a  good  basis  for  further  work. 

19.11.17.  Condition. — Very  satisfactory.  Ectropion  of  lower  lid  which  falls  away 
from  eye. 

19.11.17.  Operation. — For  lower  lid.  (1)  Implantation  of  small  piece  of  cartilage 
to  stiffen  lower  lid.  (2)  Small  plastic  tip  of  nose. 


Fid.  644.— Condition. 


Fia.  C45. — Excision  of  scar,  outlining  of  skin  flaps, 
and  muscle-swing. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


319 


C  AT 

t    Sopporf     low.r    |i4. 


FIG.  040.— After  first  plastic. 


Fia.  047. — Cartilage  graft  to  lower  lid  and  small  nose 
plastic. 


FIG.  648.— Final. 


PLASTIC   SURGERY 

CASE  603 

Tliis  officer  is  wearing  a  right  artificial  eye,  and  the  left  lower  lid  is  the  seat  of  a  eicatrieial 
ectropion  combined  with  loss  of  about  a  quarter  of  the  lid  edge. 

In  this  type  of  injury  it  has  been  found  of  great  value  to  support  the  reconstructed  lid 
by  'ocal  fat-flaps  turned  up  from  the  neighbouring  region.  These  fat-flaps  are  sutured, 
if  possible,  to  the  periosteum  over  the  neighbouring  bones,  so  as  to  help  to  raise  the  lid. 

In  this  particular  ease,  after  excision  of  the  scar,  deep  tissue  flaps  were  raised  from 
beneath  the  margins  of  the  wound  and  sutured  across  the  area  of  the  depression  thus — 
one  from  over  the  malar  bone  was  swung  across  towards  the  inner  canthus,  while  the  other, 
from  the  infra-orbital  region,  was  swung  across  towards  the  outer  canthus,  a  deep  catgut 
suture  fixing  them  to  the  periosteum.  In  addition  to  the  excision  of  the  scar  an  appropriate 
cut  was  made  to  allow  an  adequate  swinging  advancement  of  the  flaps. 

In  fig.  651,  which  represents  the  result  some  three  weeks  after  operation,  it  will  be 
noted  that  the  lid-edge  has  a  notch  and  a  depression  at  the  line  of  suture.  Neither  of  these 
deficiencies  was  present  at  the  time  of  operation,  and  it  was  interesting  to  note  that,  after 
an  interval  of  four  months,  in  which  massage  and  movements  had  been  undertaken,  that 
both  these  minor  defects  have  been  rectified.  The  result,  therefore,  is  one  which  is  very 
nearly  perfect.  It  will  be  observed,  however,  that  the  outer  canthus  has  been  displaced 
mesially,  which  is  due,  of  course,  to  the  suture  of  a  lower  lid  from  which  a  portion  was  missing. 
In  this  operation  I  had  the  valuable  assistance  of  Lt.-Col.  S.  H.  McKec,  C.M.G.,  C.A.M.C. 

Operation  notes  : 

22 . 6 . 18 .  Operation. — Free  excision  of  scar,  which  was  continued  up  to  the  conjunctiva. 
It  was  decided  not  to  cut  any  flaps  on  this  occasion  ;  but  to  support  the  lid  in  its  new  position 
two  fat-flaps  were  raised  from  the  malar  and  infra-orbital  regions  and  sutured  together. 
(Lt.-Col.  McKec  assisted  at  this  operation.) 

Immediate  result  very  satisfactory.  Later,  a  slight  dragging  downward,  owing  to 
some  remaining  scar-tissue,  is  occurring. 


!•'»:.  049.— Healed  condition. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


321 


FIG.  650. — Excision  of  scar  and  subcutaneous  fat  swings 


FIG.  651. — Final.     (Intermediate  stage  mentioned  in 
text  is  not  available.) 


21 


PLASTIC    SURGERY 


CASE  123 

The  inner  half,  or  more,  of  the  lower  lid  has  been  destroyed,  while  the  remaining  outer 
portion  is  caught  up  in  a  deep  depressed  scar  descending  from  the  socket  to  the  cheek,  pro- 
ducing a  cicatricial  cctropion.  There  was  also  loss  of  the  infra-orbital  bony  support. 

The  method  of  repair  was  by  flaps,  of  which  the  outer  consisted  of  the  normal  remaining 
lid.  At  the  junction  of  the  skin  and  the  mucous  membrane,  on  the  inner  quadrant  of  the 
defect,  there  was  a  distinct  edge,  which  was  utilised  to  form  the  new  lid  margin  of  the  inner 
half.  It  contained,  of  course,  no  eyelashes.  The  conjunctiva  and  skin-covering  for  the  new 
lid  were  thus  provided,  and  the  support  was  obtained  by  the  use  of  subcutaneous  tissue- 
flaps,  which  were  brought  up  beneath  the  new  lid  and  sutured  to  the  periosteum  in  such 
a  way  as  to  raise  and  support  the  flaps.  A  secondary  defect  now  existed  beneath  the  new 
lid,  and,  in  order  to  take  off  any  tension,  an  advancing  flap  was  made  from  the  cheek.  This 
was  first  held  well  up  in  position  by  deep  catgut  suture,  which  took  its  purchase  from  the 
periosteum  in  the  inner  canthus  region.  By  this  careful  suturing  of  the  flaps,  the  subsequent 
retraction  was  reduced  to  such  small  extent  that  a  very  satisfactory  lid  was  produced  and 
an  artificial  eye  could  be  worn.  A  homologous  cartilage  globe  was  later  inserted  behind 
the  conjunctiva,  to  give  more  prominence  to  the  artificial  eye  (eight  months  after  the  plastic). 
The  final  photograph,  taken  a  year  after  the  plastic,  shows  the  result  of  both  procedures. 
Both  movement  and  projection  of  the  eye  were  good.  Diagrams  of  the  flaps  used  in  the 
first  operation  (9.2.17)  are  shown,  fig.  653.  The  special  arrangement  of  the  subcutaneous 
tissue  is  not,  however,  illustrated,  but  the  manner  in  which  flap  B,  C,  raises  and  supports 
flap  A  is  graphically  described.  Condition  eight  months  later,  and  second  operation  notes 
are  appended  : 

26. 10. 17.  Condition. — Result  of  previous  operation  good.  Scars  have  become  almost  in- 
visible, but  a  notch  is  present  in  lower  eyelid  and  the  eye  is  not  sufficiently  mobile  or  projected. 

26.10.17. — For  projection  and  mobility  of  artificial  eye.  Homologous  cartilage 
globe  inserted  under  cocaine  anaesthesia.  The  conjunctiva  was  packed  with  20  per  cent, 
cocaine  and  horizontal  incision  made  in  it.  The  cartilage  globe  inserted  in  two  pieces  in 
the  form  of  a  cup  and  ball,  and  the  mucous  membrane  stitched  with  horsehair. 


Fio.  65?.— Healed  condition. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


323 


Note. — Some  pain  experienced. 

Result. — Owing  to  not  having  quite  separated  the  deep  tissue  sufficiently  there  was  a 
little  tension  on  one  stitch,  which  gave  way,  and  a  small  piece  of  cartilage  became  exposed. 
This  is  healing.  (20.11.17.) 

10.1.18.— Artificial  eye  fitted. 


FIG.  G53. — Excision  of  scar  and  outlining  of  flaps. 


Fid.  654. — Suture. 


O.  053. — Immediately  after  plastic. 


FIG.  656.— Final. 


.-{•_'  I 


PLASTIC  SURGERY 


TWO  M»PS    of1  remaining    portion*  oV 

l»w*r  lid  .     Deficiency  of  pAlpcfer*l 

sbi(t>d    from  rb«  cenfre   o\-  th«  lid  folh»'n*n«r 

hide   where   \f%  absence   should  btlrss  nofice&b!«. 


l\ 


\  \ 


CASE  356 

This  minor  injury  of  the  lower 
lid  resulted  in  the  loss  of  the 
middle  half  of  the  edge.  Its  repair 
was  carried  out  in  the  form  of  a 
compromise,  thus  :  a  small  stump 
of  the  lid -edge  at  the  inner  canthus 
was  freed  by  an  incision  extending 
down  the  cheek  from  the  inner 
canthus,  and  another  parallel  to  it, 
starting  opposite  the  free  end  of 
this  remnant.  It  could  then  be 
swung  across  to  meet  the  normal 
lid-edge  of  the  outer  remaining 
portion,  to  which  it  was  sutured. 
The  idea  of  doing  this  was  to 
transfer  the  deficiency  of  lid  from 
the  centre,  where  it  was  very 
noticeable  and  left  the  globe  con- 
siderably uncovered,  to  the  inner 
canthus  region  in  which  its  loss 
would  appear  to  be  of  less  conse- 
quence. The  eye,  before  and  after, 
is  illustrated. 


Flo.  657. 


Fio.  658. — Healed  condition. 


Fio.  659. — Defect  camouflaged  by  translation  nearer 
inner  canthus. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


325 


CASE  511 

A  companion  case  to  the  previous  one  is  shown  here.  But  in  this  instance  the  direction 
of  the  wound  is  different,  and  the  inner  half  of  the  lid  remains  while  the  outer  has  been 
destroyed.  Free  excision  of  scar  was  carried  out  as  usual.  The  lid  was  raised  into 
position,  and  a  descending  flap  from  the  upper  lid  brought  down  with  its  pedicle  at 
the  outer  canthus.  Similarly,  a  cheek-flap  was  swung  inwards  to  fill  up  the  gap  previously 
occupied  by  the  scar.  The  subcutaneous  tissue  was  again  manipulated  to  form  a  support 
of  the  lid.  The  result  was  sufficiently  encouraging,  as  the  level  of  the  new  socket  was  good. 
However,  as  fig.  661  demonstrates,  the  outer  canthus  was  considerably  contracted.  An 
Esser  inlay  was  therefore  carried  out,  and  the  extent  of  the  skin-grafted  cavity,  prior  to 


Inla 


y 
fri 


5ock«?t. 


o&Uiorc 


external    Incision.  . 
/• 


FIG.  600. — Healed  condition. 


FIG.  661. — After  first  plastic. 


FIG.  662. — To  indicate  epithelial  inlay. 


removal  of  the  model,  is  shown  in  outline,  fig.  662.  This  grafted  area  ran  externally  to 
the  existing  canthus,  so  that,  in  addition  to  deepening  the  lower  fornix,  the  canthus  should 
be  split  open  to  a  greater  extent.  The  epithelialisation  of  the  pocket  was  very  satisfactory, 
and  an  artificial  eye  was  carried  comfortably.  The  last  photograph  was  taken  two  and  a 
half  months  after  the  inlay,  and  shows  only  a  minor  effect  in  contour  of  the  lid. 


FIG.  663. — Before  canthoplasty. 


FIG.  604  —  Final. 


3-20 


PLASTIC    SURGERY 


CASE  81 

This  is  a  class  of  case  in  which  satisfactory  results  have  not  been  obtained  in  our  ex- 
perience. 

There  is  ptosis,  lymph-oedema,  and  immobility  of  the  upper  lid,  whose  edge  is  also 
partly  destroyed.  The  whole  of  the  lower  lid,  together  with  a  considerable  portion  of  the 
bony  ring,  ha's  been  shot  away.  The  fig.  669  of  the  result  is  more  flattering  than  was  the 
actual  appearance,  and  the  procedure  is  hardly  justifiable  in  the  majority  of  cases,  unless 
an  operation  for  ptosis  can  be  satisfactorily  added  to  elevate  the  upper  lid.  The  lid  may 
also  be  held  up  by  studs  on  the  artificial  eye. 

Strange  to  say,  this  patient,  with  a  fixed  staring  eye  whose  level  was  considerably 
below  its  opposite  member,  expressed  himself  as  being  very  pleased  with  the  result,  and 
would  not  wear  a  shade.  More  especially  with  the  eye  than  with  any  other  restoration 
of  the  face,  does  an  inferior  result  give  dissatisfaction  to  the  patient,  and  as  the  eye  is  easily 
covered  with  a  shade  that  looks  well,  anything  short  of  a  perfect  result  is  frequently  wasted. 

The  justification  for  such  operation  lies  in  the  possibility  that  the  first  result  may 
be  converted  into  a  success  at  some  future  date. 

The  first  two  operations  were  done  in  conjunction  with  Captain  Williams,  the 
ophthalmic  specialist,  who  designed  the  temporal  flap  "  A  "  in  the  diagram. 

29.9.16.  Operation. — Excision  of  scar.  An  attempt  was  made  to  form  the  lower 
lid  by  sliding  and  undercutting  the  mucous  membrane  of  the  upper  lid  and  stitching  it  to 
the  freshened  edge. 

1.12.16.  Operation. — An  incision  was  made  on  the  upper  border  of  the  eyelid  and 
undercut  to  the  depth  of  \  in.  The  scar,  which  radiated  from  the  external  angle  was  ex- 
cised, and  a  flap  4£  in.  long  from  the  right  temporo-frontal  region  was  cut,  its  base  including 
the  temple  artery.  This  was  freed  and  brought  down  to  form  the  inner  surface  of  the 
lower  lid.  Two  deep  blanket  sutures  were  put  in  to  hold  the  inner  border  of  this  flap  down 
to  the  bottom  of  the  socket,  and  brought  out  about  one  inch  below  the  new  palpebral  margin 
and  tied  over  a  piece  of  gauze,  the  outer  edge  of  the  flap  was  accurately  stitched  to  the 
split  and  loosened  lower  lid,  the  rest  was  sewn  up  accurately  with  drainage  at  its  outer  part. 


Fio.  005.— Shortly  after  wound. 


Fid.  666. — Healed  condition. 


INJURIES    IN   THE   REGION   OF   THE   EYES 


327 


28.4.17.— Result  of  the  operation  1.12.16.  Satisfactory  in  that  it  held  an  artificial 
eye,  but  too  much  of  this  eye  was  exposed. 

28.4.17.  Operation. — An  incision  was  made  along  the  summit  of  the  skin  forming  the 
lower  lid  and  carried  into  the  socket  near  the  outer  angle.  This  released  a  flap  of  skin  with 
its  raw  surface  outwards,  which  was  sutured  to  the  freshened  outer  angle.  Considerable 
gap  was  thus  formed  in  the  lower  lid,  which  was  covered  in  by  a  free  skin-graft  from  the 
right  mastoid  region,  including  a  few  lines  of  hair. 

Result. — Partially  successful. 


Fio.  667.— Flap. 


Fio.  668.— Suture. 


Fio.  669. —  Unsatisfactory  result. 


328 


PLASTIC    SURGERY 


CASE  227 

This  is  shown  as  it  illustrates  the  condition  of  lymph-oedema  of  the  lower  lid.  I  have 
not  seen  one  of  these  persist  after  excision  of  the  scar  has  been  efficiently  carried  out.  Flap 
is  indicated  in  the  outline. 


Fio.  670.— Healed  condition. 


FIG.  671. — Excision  of  scar  and  swinging  of  cheek  flap. 


Fio  672. — After  excision  of  scar. 


INJURIES   IN   THE   REGION   OF   THE   EYES  320 


SUPERIOR    BLEPHAROPLASTY 

Two  cases  of  this  reconstruction  are  included  in  this  series,  and  both,  to 
all  intents  and  purposes,  show  losses  of  the  whole  upper  lids. 

Two  minor  injuries,  with  traumatic  ectropion  of  the  upper  lid,  occurred 
in  Cases  365  and  517.  See  pp.  284  and  288. 

No.  365  was  treated  by  flap  operation  and  resuture,  while  No.  517  was 
treated  by  the  epithelial  outlay  method,  which  will  be  described  under  "  Burns 
of  the  Lid  "  in  the  next  section. 

For  the  total  reconstruction  of  an  upper  lid  in  which  the  conjunctiva  is 
united  by  scar  tissue  to  the  eyebrow,  an  extension  of  the  outlay  method  is 
suitable.  The  lid  that  results  is  mobile,  and  in  the  position  of  rest  covers 
the  artificial  eyes  satisfactorily.  It  is  not  long  enough  to  close  over  the  globe 
in  normal  position — the  movement  upwards  by  the  remains  of  the  levator 
attachment  is,  however,  quite  observable.  The  most  serious  deficiency  of  the 
operation  is  the  absence  of  the  eyelashes.  The  latter  defect  can,  I  am  sure, 
be  diminished  by  tattooing  the  lid-edge,  or  by  the  use  of  grease  paint.  In 
one  case  a  line  of  hairs  from  the  eyebrow  was  included  in  the  new  lid,  but  the 
result  was  not  very  good.  The  author  has  no  experience  of  implantation  of 
single  hairs  to  form  an  eyelash.  When  the  loss  of  the  upper  lid  involves  more 
of  the  conjunctiva  than  of  the  skin  the  latter  tucks  itself  in  beneath  the  roof  of 
the  orbit.  To  form  an  eyelid  from  this  condition,  attempts  have  often  been 
made  to  undercut  the  skin  from  the  conjunctival  aspect,  and  to  epithelialise 
its  back  surface  after  the  method  of  Esser.  For  this  condition  the  author 
has  advised  the  implantation  of  auricular  cartilage  into  the  skin  remains  of 
the  lid,  which  is  subsequently  swung  downwards  as  a  combined  skin-cartilage 
flap,  similar  to  the  author's  other  skin-cartilage  "  swings." 

The  original  skin  surface  would  thereby  line  the  new  lid,  and  a  new  external 
covering  provided  by  skin -graft  would  form  an  efficient  covering  to  prevent 
contraction.  The  author  has  not  performed  this  operation,  but  has  advised 
it,  and  it  would  seem  a  reasonable  procedure.  From  the  use  of  a  frontal  flap 
no  movement  in  the  lid  could,  of  course,  be  hoped  for,  unless  either  the  levator 
could  be  attached  to  it  or  a  muscle  strip  introduced. 


330 


PLASTIC    SURGERY 


CASE  634 

The  loss  of  the  upper  lid  due  to  this  injury  is  sub-total,  since  a  minute  portion  of  the 
lid-edge  remains  at  the  inner  eanthus.  The  eyebrow  has  been  partly  destroyed  and  is  the 
seat  of  a  large  depressed  scar.  The  lower  lid  is  normal,  but  the  outer  eanthus  is  caught 
in  scar. 

The  method  of  treatment  consisted  in  the  use  of  an  Esser  skin-graft  for  the  author's 
outlay  operation,  described  in  the  section  on  "  Burns."  The  first  graft  that  was  inserted  was 
too  short,  and  a  second  one  was  added.  The  deficiency  of  the  eyebrow  was  corrected  by 
a  whole-thickness  free  graft  of  hairy  scalp  taken  from  behind  the  right  ear.  The  graft  was 
successful,  and  probably  about  half  the  hairs  continued  to  live  and  grow  in  the  right  direction. 
The  final  photograph  is  taken  without  any  darkening  of  the  new  lid-edge  ;  but  the  effect 
of  the  eye  was  markedly  improved  when  a  dark  line  was  drawn  along  the  part  where  the 
eyelashes  should  be.  Operation  notes  follow  : 

20.3.18.  Operation. — Epithelial  outlay  for  new  upper  lid  (partial).  Excision  of  scar 
on  eyelid  and  eyebrow. 

2.4.18.   Operation. — Removal  of  inlay. 

Result. — Partially  satisfactory.  The  amount  grafted  was  too  small  and  showed  tendency 
to  retract. 

13.5.18.  Operation. — Further  to  lengthen  eyelid  by  outlay.  Incision  made  above 
previous  graft.  Large  inlay  inserted. 

18.6.18.   Operation. — Palpebral  fissure  widened  under  local  anaesthetic. 

20.8.18. — Result  of  last  epithelial  outlay  satisfactory.     Lid  rather  too  long. 

20.8.18.  Operation. — To  correct  loss  of  eyebrow  hair.  Excision  of  scar  in  region  of 
eyebrow.  A  free  graft  of  whole-thickness  skin  from  behind  the  right  ear  was  cut  to  requisite 
size.  Hairs  had  not  been  shaved  but  clipped  moderately  short,  and  their  direction  calculated 
to  be  correct  when  grafted  into  position.  The  fatty  tissue  was  scraped  off  the  back  of  this 
free  graft.  Its  length  was  that  of  an  entire  eyebrow,  and  less  than  \  in.  in  breadth.  It 
was  sewn  into  position.  In  order  to  keep  it  firmly  down  and  on  tension,  a  stent  mould 
was  laid  over  the  graft  and  catgut  sutures  were  passed  over  this  mould  from  skin  to  skin 
to  retain  it  in  position. 

Stent  removed  eleventh  day.     Graft  appears  satisfactory. 


Fio.  073. — Loss  of  upper  lid  and  middle  one-third 
of  eyebrow. 


FIG.  074. — After  epithelial  outlay  to  lid,  and  whole 
thickness  scalp  graft  to  eyebrow. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


331 


CASE  394 

In  this  case  there  is  absolutely  no  remnant  of  the  upper  lid  remaining,  and  the  con- 
junctiva has  been  drawn  up  by  scar  tissue  to  the  eyebrow,  which  in  its  turn  has  been  dragged 
down.  The  lower  lid  is  normal. 

The  Esser  graft  was  used  by  the  author's  outlay  method,  a  few  of  the  eyebrow  hairs 
being  included  in  that  portion  which  was  taken  down  after  the  graft  had  been  made.  A 
photograph  of  the  result  was  taken  six  months  after  the  operation.  Though  by  no  means 
perfect,  it  was  distinctly  gratifying. 

The  condition  is,  obviously,  capable  of  improvement,  but  the  exigencies  of  the  Service 
demanded  this  officer's  return  to  duty. 

19.12.17.  Operation. — For  formation  of  upper  eyelid.  Method:  reverse  epithelial 
inlay.  Incision  made  through  the  lower  part  of  the  eyebrow  to  include  a  few  hairs,  and 
laterally  towards  each  ocular  angle  about  two  millimetres  above  the  muco-cutaneous  junction. 
Incision  deepened  with  the  knife,  which  was  carried  in  the  soft  tissue  lying  between  the 
conjunctiva  and  the  floor  of  the  frontal  sinus.  Impression  of  cavity  taken  in  the  stent  and 
epithelial  inlay  made  in  usual  manner.  Incision  closed. 

Eleventh  day.  Incision  under  local  anaesthetic  along  original  incision.  Removal  of 
stent  two  days  later.  Perfect  epithelialisation. 

Complication. — Acute  tonsillitis.     Area  of  graft  removal  slightly  infected. 

4.1.18.    Operation. — Insertion  of  glass  shell.     Upper  lid  looks  fairly  satisfactory. 

22.4.18. — Result  of  previous  operation  satisfactory  except  for  small  central  portion, 
which  did  not  take.  This  prevented  the  new  eyelid  from  descending  in  its  central  part. 

22.4.18.  Operation. — Plastic  upper  lid.  Excision  of  diamond-shaped  pattern  of  scar 
tissue  caused  by  failure  of  graft,  which  allowed  lid  on  resuture  to  descend.  Scar  at  inner 
canthus  also  excised.  Note  re  skin-graft  first  operation.  The  graft  was  very  thick  and 
has  grown  hairs  all  over  it.  The  patient  has  had  a  severe  septic  throat,  followed  by  a  septic 
area  at  the  place  where  the  graft  was  taken. 

Present  condition. — Very  satisfactory.     Discharged  to  duty,  5.6.18. 


Fia.  675. — Total  loss  of  upper  lid. 


Fid.  676. — After  epithelial  outlay. 


332  PLASTIC    SURGERY 


INJURIES    OF    THE    SOCKETS 

Plastic  problems  in  connection  with  the  empty  socket  are  mainly  of  two 
varieties.  In  one  very  large  series  of  cases  common  to  all  war-injury  eye  clinics, 
there  is  a  deficiency  of  conjunctiva  causing  entropion  and  contracted  socket. 
The  other  class  of  cases,  which  is  not  so  confined  to  war  injuries,  presents  a 
sunken  socket,  in  which  the  artificial  eye  sits  far  back  and  immobile.  In  the 
contracted  socket  a  deficiency  of  lining  membrane  may  be  present  in  either 
the  upper  or  lower  cul-de-sac. 

In  cases  where  the  lower  cul-de-sac  is  flattened  out  until  it  is  on  a  level 
with  the  lid-edge  a  flap  of  mucous  membrane  attached  to  the  lower  lid  edge 
may  be  raised  and  tucked  down  perpendicularly  below  the  lid-edge  into  an 
incision  made  for  it,  and  held  there  by  mattress  sutures  coming  out  of  the  cheek. 
This  procedure  is  satisfactory  for  minor  cases,  but  for  the  severer  forms  of 
cicatricial  contraction  the  author's  practice  is  to  insert  the  Esser  epithelial 
inlay — for  the  details  of  which  see  "Principles." 

This  is  inserted  through  an  incision  in  the  conjunctiva,  and  carried  down 
for  a  suitable  distance  behind  the  lower  lid.  Great  care  must  be  taken  to 
distend  the  skin-grafted  cavity  by  a  mould.  A  shell  with  a  deep  edge  to 
go  into  the  sulcus  may  be  used  as  a  retentive  apparatus.  Sometimes  the 
epithelialised  cavity  is  maintained  by  black  gutta-percha,  which  is  moulded 
into  the  shape  of  the  socket  and  new  cul-de-sac  :  in  this  may  be  cut  hollows 
for  drainage ;  but  probably  the  best  method  far  keeping  the  socket  from 
again  contracting  is  to  take  an  accurate  impression  and  have  a  vulcanite 
model  made  for  insertion.  Close  co-operation  with  an  expert  dental  surgeon 
is  advisable. 

It  is  most  important  that  the  grafted  sulcus  be  kept  fully  on  the  stretch 
for  a  considerable  period  after  the  operation,  and  at  no  time  must  the  pros- 
thesis be  removed  for  more  than  a  few  minutes.  If  this  rule  is  followed  there 
\\ill  come  a  time,  which  varied  in  our  experience  with  different  cases,  Avhen 
the  skin-graft  will  cease  to  contract.  This  may  take  three  or  more  months, 
and  seldom  occurs  before  two  months.  When,  however,  the  contraction  ceases 
the  prosthesis  may  be  left  out  for  nights  or  even  days  without  jeopardising 
the  replacement  of  the  apparatus.  It  is  then  quite  safe  to  insert  the  permanent 
artificial  eye. 

Another  cause  of  failure  in  this  operation  is  as  follows : 

The  skin-graft  is  cut  badly,  and  is  wrapped  around  the  mould  without 
sufficient  care  being  taken  to  have  every  surface  covered.  There  are  thus  some 
raw  areas  in  the  new  pocket  which  ulcerate  and  fail  to  become  epithelialised- 


INJURIES    IN    THE    REGION    OF   THE   EYES  3,33 

contraction  and  infection  are  then  liable  to  supervene.  Marked  infection  of 
the  socket  is  sometimes  seen  as  a  result  of  the  insertion  of  skin-graft,  but  this 
may  be  easily  controlled  by  ordinary  methods. 

The  method  of  insertion  of  the  Esser  inlay  has  been  modified  in  the  practice 
of  the  Queen's  Hospital,  Sidcup,  by  Major  C.  W.  Waldron,  C.A.M.C.,  who  first 
introduced  one  of  these  inlays  through  the  mucous  membrane,  as  in  contra- 
distinction to  the  described  Esser  method,  in  which  the  inlay  is  inserted  through 
a  skin  incision.  (This  was  on  a  lower  lip  case.) 

There  are  certain  advantages  and  disadvantages  in  either  method.  In- 
sertion from  the  skin  aspect  involves  a  more  difficult  operation,  external  scar, 
and,  if  infection  should  occur,  a  fistula.  Should  the  dissection  of  the 
cavity  towards  the  mucous  surface  not  be  carried  sufficiently  near  the  con- 
junctiva, a  raw  area  is  left  when  the  model  is  removed  from  the  conjunctival 
aspect,  which  is  liable  to  contraction.  In  one  case  of  the  author's  this  shut  off 
the  epithelial  cavity  from  the  socket.  On  the  other  hand,  infection  is  much  less 
liable  to  occur,  and  possible  contraction  is  less  to  be  feared.  Incision  through 
the  conjunctiva  has  the  advantages  of  easy  removal  of  the  model,  simplicity 
of  performance,  and  ready  application  of  the  retention  prosthesis  after  removal 
of  the  stent.  There  is,  however,  a  greater  probability  of  infection,  and  there 
is  a  tendency  to  push  scar  tissue  on  one  side  rather  than  to  excise  it. 

The  author  has  not  been  successful  in  grafting  mucous  membrane  to  form 
culs-de  sac,  but  he  agrees  with  the  suggestion  made  to  him  by  Colonel  Sir  Wm. 
Lister  and  Captain  Richard  Cruise,  that  in  making  these  epithelial  grafts  as 
much  conjunctiva  as  possible  should  be  preserved  on  the  free  portion  of  the 
ocular  surface  of  the  lid. 


PLASTIC    SURGERY 


CASES  511  AND  357 

One  of  the  most  successful  examples  of  treatment  of  a  contracted  socket  is  Case  511, 
which  has  been  described  under  "  Eyelids." 

In  Case  357  there  was  cicatricial  contraction  in  both  the  upper  and  lower  fornices, 
and  the  original  Esser  Inlay  was  attempted  through  both  lids  by  external  incision.  The 
upper  was  successful  in  producing  a  satisfactory  pocket,  but  the  lower  failed  in  that  the 
cavity  made  for  the  model  was  too  small  and  not  sufficiently  near  the  conjunctiva.  In 
addition,  scar  tissue  was  left  between  the  model  and  the  floor  of  the  socket.  The  stent 
was  removed  on  the  twelfth  day.  It  was  then  found  necessary  to  make  a  considerable 
incision  through  the  conjunctiva  before  the  epithelialiscd  cavity  was  reached.  A  small 
epithelial  external  fistula  also  existed.  The  operation  was  a  failure  as  regards  the  lower 
lid.  At  a  later  date  this  was  reoperated,  after  which  an  artificial  eye  could  be  fitted.  The 
appearance,  however,  was  far  from  satisfactory,  as  there  was  ptosis  of  the  lid  with  cversion 
of  the  inner  ciliary  margin.  It  is  quite  possible,  however,  that  the  artificial  eye  might 
have  been  made  to  look  much  better  by  further  corrections  of  the  lid-edge  and  an  operation 
for  ptosis.  Treatment,  however,  was  not  continued,  as  the  socket  was  still  suffering  from 
a  mild  chronic  infection.  The  black  gutta-percha  model  which  retained  the  two  grafts  in 
position  is  illustrated,  showing  clearly  the  holes  drilled  in  it  for  drainage. 


FIG.  677. — Mould  in  position. 


Fio.  678. — Final  :  Failure  as  regards  lower  lid. 


Flo.  079. — Mould  removed. 


Fio.  080. — Another  view  of  mould. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


335 


CASE  614 

The  tarsal  plate  and  inner  layers  of  the  lower  lid  have  been  destroyed.  There  is  no 
remnant  of  the  lower  sulcus,  and  there  is  also  cicatricial  contraction  and  shortage  of  mucous 
membrane  in  the  inner  aspect  of  the  upper  cul-de-sac. 

A  large  epithelial  inlay  was  inserted  beneath  the  lower  lid  and  contracted  area  of  the 
upper.  The  graft  was  retained  by  the  large  gutta-percha  model  seen  in  fig.  682.  The  shape 
of  the  model  underneath  the  lower  lid  is  also  seen,  causing  the  slight  swelling  below  the  socket. 

Perfect  epithelialisation  occurred.  A  deep  V  Y  operation  was  performed  on  the  cheek, 
which  had  for  its  object  the  raising  of  this  newly  formed  lower  cul-de-sac.  The  result  was 
moderately  successful. 

Operation  notes  : 

12.8.18. — Incision  was  made  along  muco-cutaneous  junction  of  lower  lid,  and  deepened 
f  in.  by  undercutting  the  skin  over  the  infra-orbital  margin.  The  upper  lid  was  also  freed 
from  the  adhesion,  and  an  impression  of  the  freshly  cut  area  taken  in  stent  and  covered 
with  Thiersch  graft  from  left  arm.  Flavine  packing  to  remainder  of  socket. 

Result. — Satisfactory.  Graft  maintained  by  prosthesis,  which  has  been  worn  since 
above  operation. 

11.10.18.  Operation. — A  long  V  incision  and  Y  suture  was  carried  out  to  raise  the 
new  lower  fornix.  Adjustment  of  upper  lid  at  inner  canthus. 


Fio.  681. — Loss  of  lower  fornix. 


Fio.  082. — Showing  prosthesis  in  position. 


Fio.  683. — Prosthesis  replaced  by  artificial  eye. 


336  PLASTIC    SURGERY 

SUNKEN  SOCKETS 

The  disabilities  of  this  condition  are  obvious.  The  eye  is  seldom  sufficiently 
prominent,  and  the  upper  lid  is  concave.  In  addition,  a  gunshot  injury  most 
frequently  leaves  a  stump  which  very  poorly  imparts  movement  to  the  artificial 
eye.  Mule's  globes—  sewn  in  at  the  time  of  the  removal  of  the  eye— have,  in  cer- 
tain ophthalmic  surgeons'  hands,  produced  satisfactory  results ;  but  when  the 
socket  is  healed  and  sunken,  good  results  may  be  obtained  by  implantation  of 
cartilage  or  fat.  Fat  has  been  used  for  some  years.  In  1915  Carlotti  and 
Bailleul,  of  Paris,  described  the  use  of  cartilage.  Captain  J.  L.  Aymard  described 
an  independent  modification  of  this  method,  in  1917.  The  operation  has  stood 
the  test  of  time,  and  has  the  great  natural  advantage  over  the  Mule's  globe  in 
that  it  is  a  living  tissue  implantation  and  not  a  foreign  body.  For  primary 
enucleation  of  the  eye  this  implant  has  been  modified  by  stitching  the  muscles 
to  the  cartilage  globe  in  approximately  their  anatomical  positions  (author). 
Two  cases  only  have  been  done  by  this  method,  one  of  which  was  a  failure, 
owing  to  infection  of  the  cartilage  as  a  result  of  an  accident  in  the  theatre.  The 
next  development  in  the  attempt  to  produce  artificial  eyes  that  move  well  is 
one  which  has  its  basis  in  the  Esser  method  of  skin-grafting.  Instead  of 
inserting  a  cartilage  globe  into  the  orbital  tissues  between  the  muscles,  it  occurred 
to  the  author  to  make  an  epithelialised  cavity  in  the  same  situation  which 
should  carry  a  deep  prolongation  of  the  artificial  eye.  This  extension  would 
then  be  gripped  by  the  muscles  and  movement  transmitted  to  the  artificial 
eye.  The  whole  process  is  in  a  state  of  flux,  and  no  definite  pronouncement 
can  be  made. 

Two  out  of  three  cases  have  been  brought  to  a  stage  in  which  a  permanent 
epithelialised  cavity  is  situated  in  the  centre  of  the  orbit.  The  development 
of  the  artificial  eye  to  fit  the  same  is  at  the  present  time  in  the  hands  of  the 
eye-makers  ;  but  the  two  cases  above  mentioned  now  wearing  a  special  glass 
eye  designed  for  this  method  are  amongst  the  following. 

For  the  making  of  an  epithelial-lined  cavity  in  the  orbit,  incision  is  made 
as  for  the  cartilage  operation,  and  a  conveniently  sized  Mule's  globe  inserted 
so  that  the  conjunctiva  can  be  re-sewn  over  it  without  tension.  A  very  thin 
'Ihicrsch  graft  is  then  wrapped  around  the  Mule's  globe.  When  the  excess 
of  the  graft  has  been  snipped  of!  with  the  scissors  the  graft  and  globe  are  inserted 
behind  the  conjunctiva,  which  is  sewn  up  over  it.  This  mould  stays  in  for  a 
varying  time.  In  one  case  it  came  out  the  next  day,  but  in  the  second  case 
the  Mule's  globe  was  retained  for  five  days,  while  in  the  third  the  Mule's  globe 
did  not  make  its  appearance  for  five  weeks,  when  the  determining  factor  of  its 


INJURIES    IN   THE    REGION   OF   THE    EYES  337 

extrusion  appeared  to  be  an  infection  following  the  fitting  of  an  artificial  eye, 
there  being  a  slight  raw  area  in  the  conjunctiva  apart  from  the  area  operated. 
On  the  extrusion  of  the  Mule's  globe,  a  prosthesis  was  inserted  after  an  impres- 
sion had  been  taken  by  a  dental  surgeon.  In  order  to  keep  this  prosthesis  in 
position  an  apparatus  may  be  worn  (see  p.  204).  It  remains  to  fit  an  arti- 
ficial eye  which  carries,  from  its  posterior  surface,  a  stalk  or  prolongation  at 
the  end  of  which  is  a  blob  fitting  snugly  into  the  epithelial  cavity.  Fig.  700 
shows  the  view  of  the  epithelial  cavity  that  has  been  produced,  and  it  should 
be  noted  that  these  cavities  maintain  themselves  now  for  several  days  without 
contraction  and  without  the  wearing  of  any  retaining  apparatus.  In  adapting 
the  artificial  eye  to  this  principle,  the  author  is  greatly  indebted  to  Captain  W. 
Kelsey  Fry,  R.A.M.C.,  M.C.,  and  Captain  Gordon  Johnson,  and  many  others 
of  the  dental  and  medical  staffs. 

In  regard  to  the  invention  of  an  artificial  eye  adapted  to  this  operation, 
the  author  wishes  to  express  his  appreciation  of  the  readiness  which  the  artificial 
eye-makers  have  shown  in  the  experimental  stage.  Case  notes  of  the  two  cases 
and  illustrations  follow. 


22 


338 


PLASTIC    SURGERY 


CASE  641 

Tin's  socket  liad  a  double  deficiency — that  of  complete  absence  of  the  lower  fornix 
combined  with  a  markedly  sunken  socket. 

A  double  procedure  was  outlined  :  Firstly  the  filling  of  the  socket  by  cartilage  globe  opera- 
tion, and,  secondly,  an  epithelial  inlay  to  the  lower  lid.  The  cartilage  operation  was  per- 
formed lirst.  as  the  socket  was  a  very  clean  one.  The  stump  produced  by  the  cartilage 
implantations  is  well  seen  in  the  figs,  as  a  globular  swelling  behind  the  conjunctiva. 

The  inlay  operation  was  performed  for  me  by  Captain  T.  Jackson,  R.A.M.C. 

Hoth  operations  were  successful,  and  a  clean  socket  carrying  artificial  eye,  with  moder- 
ately good  movement,  has  been  obtained.  In  regard  to  the  cartilage  implantation,  two 
pieces  were  taken  from  the  sternal  end  of  the  seventh  rib,  and  shaped  into  a  globe  and  ball, 


FIG.  684.—  Contracted  socket  and  loss  of  lower  fornix.  FIG.  085.—  After  cartilage  globe  implant. 


which  wm-  inserted  through  a  horizontal  incision  in  the  conjunctiva.     Interrupted  catgut 
was  used  lor  the  suture  material. 

A  diagram  illustrating  the  method  of  the  cup-and-ball  cartilage  implantation  is  shown, 
he  author  is  not  convinced  that  this  shape  of  cartilage  gives  any  better  result 
than  a  simple  ovoid  or  globular  form. 


Fl'J.  tixii.      ()„   admission. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


339 


Case  No.  64lA  (Lloyd). — Cartilage  implantation  at  time  of  enucleation. 
Muscles  stitched  to  cartilage.  The  cartilage  prosthesis,  in  two  pieces,  cup-and- 
ball  method,  Avas  inserted  through  a  horizontal  incision  at  the  back  of  the  socket. 
A  certain  amount  of  exposure  of  the  cartilage  followed  this  operation,  and 
some  of  the  thread  sutures  which  were  used  to  tie  the  muscles  to  the  cartilage 
came  away.  The  condition  very  rapidly  cleared  up  without  further  infection. 
It  must  be  admitted,  however,  that  when  the  artificial  eye  was  fitted  there 
was  no  appreciable  greater  movement  than  would  have  probably  been  the  case 
had  the  muscles  not  been  stitched  to  the  socket.  The  projection  of  this  eye 
is  exceptionally  good,  and  until  forced  movements  are  undertaken  detection 
of  the  artifice  is  exceedingly  difficult.  Dia- 
gram of  the  operation  and  picture  of  the 
result  are  illustrated  : 

In  those  cases  in  which  a  partial  enu- 
cleation is  indicated  it  is  considered  that 
this  cartilage  implant  would  give  as  good  a 
cosmetic  result  as  the  Mule's  globe,  with  a 
far  greater  percentage  of  permanent  success. 

Many  other  examples  of  cartilage  globe 
have  already  been  illustrated,  viz.  Cases 
292,  220,  517,  307,  558A,  in  the  previous 
chapters. 


FIG.  088. — Showing  oup-and-ball  cartilage  eye. 


Fia.  680. — Cartilage  eye-implant  at  time  of 
enucleation. 


FIG.  690. — Final. 


.'}  10 


PLASTIC    SURGERY 


CASE  519 

Wounded,  21.9.17.     Admitted,  30.9.17. 

Kye  removed. 

14.3.18.   Condition. — Sunken  socket — partial. 

14.3.18.  Operation. — For  insertion  of  glass  ball  prosthesis  with  epithelial  covering 
through  horizontal  incision  of  conjunctiva  (as  in  and  instead  of  cartilage  globe  operation). 
The  epithelium  was  sewn  over  the  glass  globe  with  fine  catgut.  Conjunctiva  sewn  up 
completely  with  horsehair. 

l'n>»ress. — At  the  end  of  five  weeks — very  satisfactory.  A  small  portion  of  the  globe 
lay  exposed  at  the  back  of  the  socket  and  was  lying  in  its  epithelialised  bed,  and  the  move- 
ment of  an  artificial  eye  fitted  thereon  was  excellent.  Three  days  after  this  fitting  the 
e< instant  manipulation  had  loosened  the  glass  globe,  and,  with  the  addition  of  sepsis,  it  was 
expelled.  During  this  period  a  small  adhesion  had  been  cut  at  the  inner  points.  The 
probable  immediate  reason  of  the  extrusion  was  :  (1)  the  manner  in  which  the  artificial 
eye  stuck  by  suction  to  the  portion  of  the  globe  exposed  ;  and  (2)  the  infection. 

Note. — The  opinion  of  Colonel  Lister  was  taken  on  this  and  similar  procedures,  and, 
in  his  opinion,  no  glass  globe  that  became  exposed  would  ever  be  retained  permanently. 


CLASS    GUOBE. 
Covr.Rirsc 


Km.  001.— Sectional  diagram  to  show  insertion  of  a  skin-covered  glass  ball. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


341 


. 


FIGS.  692,  093,  694,  695,  and  696. — At  various  stages. 


FIG.  697.— Final. 


PLASTIC    SURGERY 


CASE  459 

Wounded,  20.9.17.     Admitted,  23.9.17.     Operation,  11.3.18. 

Section  of  right  eye  socket  to  show  insertion  into  Tenon's  capsule  of  a  Mule's  globe, 
surrounded  by  Thierseh  graft,  skin-surface  centripetal.  The  skin-graft  was  tightly  sewn 
over  the  glass  globe  by  fine  catgut  sutures.  The  conjunctiva  was  sewn  up  with  interrupted 
horse  li;iir.  and  a  shell  was  placed  over  this  for  protection  and  retention  of  globe. 


txplanalory    of    model 


Qlobe 


incision 


A- Lye    lid. 
B  •  Ocular    conjunlivo 
1    C  •  Tenons     Co^sule 

D-  Epithelial    graft  sur- 
rounding 

E  - 


conjunhvci 
Artificial    eye 


F-- 


E- 


!U  . 


Fio.  698.— Diagrams  of  the  operation. 


INJURIES    IN  THE   REGION   OF   THE   EYES 


343 


FIG.  G99. — On  admission. 


FIG.  700. — Showing  epithelialised  socket. 


Fio.  701. — Final. 


344  PLASTIC    SURGERY 


OPERATION    FOR    ORBICULARIS    PALSY 

Another  type  of  plastic  operation  which  the  author  wishes  to  bring  to 
notice  is  that  for  the  palliative  treatment  of  paralysis  of  the  orbicularis  muscle. 

The  conditions  complained  of  with  this  lesion  are  pain  and  lachrymation, 
due  to  exposure  of  the  cornea,  epiphora  due  to  the  paralysis  of  the  orbicularis, 

and  headache. 

The  author's  operation  is  designed  primarily  to  overcome  the  exposure  of 
the  globe  :  the  relief  of  pain  and  epiphora  is  bound  up  in  this.  There  is,  in 
addition,  an  attempt  to  reproduce  the  lid  action. 

The  principle  involved  is  the  provision  of  closure  of  the  palpebral  fissure 
by  means  of  the  spring  support  afforded  by  a  delicate  lamina  of  cartilage, 
operating  (in  the  upper  lid)  against  the  pull  of  the  levator  palpebra?.  Success 
depends  on  the  achievement  of  just  so  much  closure  as  can  be  overcome  when 
the  levator  is  put  into  action. 

This  type  of  operation  has  been  done  on  six  occasions.  In  all,  functional 
improvement  has  been  achieved  to  a  greater  or  lesser  extent,  and  in  three  the 
cosmetic  result  has  been  distinctly  indifferent,  owing  to  prominence  of  the 
cartilage.  In  one  only  has  the  result  approached  the  author's  ideal. 

In  the  first  operation,  which  is  graphically  described  in  the  diagram 
Fig.  702,  a  slender  strip  of  cartilage  was  divided  almost  throughout  its  length, 
so  that  the  two  portions  remained  united  at  one  end.  It  was  inserted  sub- 
cutancously  through  a  small  incision  lateral  to  the  outer  canthus,  so  that  each 
portion  occupied  a  position  subjacent  to  the  lid-edge.  The  free  ends  of  the 
cartilage  were  sutured  with  catgut  through  another  incision  just  mesial  to  the 
inner  canthus.  This  caused  the  flat  strips  to  bow  forward  coincident  with  the 
contour  of  the  globe.  Fixation  of  the  graft  was  ensured  by  suture  to  the 
periosteum  at  cither  canthus.  A  difficulty  now  appeared.  Closure  had  been 
attained,  but  there  had  resulted  a  slight  projection  forward  of  the  centre  of  the 
upper  lid  from  the  globe.  This  was  assumed  to  have  been  caused  by  excessive 
length  in  the  upper  cartilage  bow,  and  a  small  piece  was  therefore  excised  from 
its  centre,  with  the  hope  that  sufficient  spring  effect  would  remain  to  secure 
closure.  This  hope,  unfortunately,  was  not  fulfilled  :  the  break  in  the  con- 
tinuity of  the  graft  allowed  the  spring  effect  gradually  to  wane. 

In  the  second  case  it  was  decided  to  over-correct  the  deformity  at  the 
outset  by  the  provision  of  a  strong  spring,  which  should  be  weakened  later  if 
necessary. 

The  cartilage  lamina  was  therefore  divided  so  that  the  two  portions  remained 
united  at  both  ends.  A  complete  ring  was  thus  formed,  which  was  inserted 


INJURIES    IN   THE    REGION    OF    THE   EYES  345 

through  an  incision  skirting  the  whole  of  the  palpcbral  fissure.  Suture  at  the 
angles  was  very  difficult,  but  the  appearance  at  the  end  of  the  operation  gave 
great  promise.  The  palpebral  fissure  remained  tightly  closed  for  some  two  or 
three  days  after  the  operation,  when  the  levator  action  began  to  assert  itself, 
the  lids  commencing  to  open  slightly  and  to  be  closed  by  the  spring. 

Then  a  misfortune  occurred,  two  stitches  giving  way  at  one  spot,  with 
infection  from  a  chronic  conjunctival  discharge  which  had  been  present  on 
admission.  The  continuity  of  the  cartilage  ring,  however,  has  persisted.  It 
is  intended  later  to  weaken  the  spring  by  thinning  the  cartilage  laminsc.  This 
should  improve  the  cosmetic  result,  and  should  diminish  the  existing  prominence 
of  the  central  portion  of  the  lids. 

A  simpler  method  of  spring  formation  was  adopted  on  subsequent  occa- 
sions, a  T-shaped  piece  of  cartilage  being  used,  with  the  stem  inserted  beneath 
the  periosteum  of  the  orbital  margin,  and  the  cross-piece  subjacent  to  the  lid- 
edge.  The  spring  closure  thus  attained  is  balanced,  in  the  upper  lid,  by  the 
action  of  the  levator  palpebrse. 

Curvature  of  the  cross-piece  in  conformity  with  the  globe  is  ensured  by 
leaving  the  perichondrium  on  the  aspect  turned  toward  the  globe.  The 
author  has  found  that  curvature  always  occurs  with  the  concavity  toward 
the  perichondrium,  and  he  has  utilised  this  property  of  grafts  in  several  of  his 
operations. 


PLASTIC    SURGERY 


CASE  740 

2.12.18.  Operation. — Cartilage  taken  from  right  costal  cartilage  in  usual  manner. 
A  thin  piece  was  then  cut  approximately  the  length  of  the  lids.  It  was  split  in  its  length, 
i  \i  <  pting  a  small  portion  across  one  end.  There  were  thus  two  rods  of  the  cartilage  attached 
at  one  end,  which  were  inserted  through  a  small  incision  in  the  right  outer  canthus  into 
the  upper  and  lower  edges  respectively.  They  were  brought  out  at  a  curved  incision  over 
the  inner  canthus,  where  they  were  sutured  to  the  periosteum.  A  small  horizontal  incision 
\\as  made  in  the  upper  lid  half-way  across  to  facilitate  the  manipulation.  The  cartilage 
at  the  outer  canthus,  where  the  two  rods  were  attached,  was  likewise  sewn  down  to  the 
periosteum. 

The  effect  was  now  to  obtain  a  strong  and  complete  closure  of  the  palpebral  fissure. 
However,  the  upper  rod  was  too  long  and  the  lid  was  not  in  apposition  with  the  globe. 
Instead  of  reopening  the  inner  canthus  incision,  where  the  fixation  of  the  rods  had  been 
difficult,  a  small  portion  was  excised  from  the  middle  of  the  rod  of  the  upper  lid.  On  tying 
the  rod  together  with  catgut  it  was  found  that  too  much  had  been  removed,  and,  had  they 
been  permanently  sutured  together,  the  lower  rod  would  have  bowed  the  lower  lid  awav 
from  the  globe.  It  was  therefore  left  unsutured  in  the  hope  that  the  spring  of  the  cartilage 
would  be  sufficient  to  give  a  partial  closure  to  the  fissure. 

Early  result. — This  was  apparently  accomplished. 

Later  result. — No  improvement.     Operation  to  be  re-done. 


"-V. 


Fios.  702,  703,  and  704.— For  description  see  text. 


INJURIES   IN   THE   REGION   OF   THE   EYES  347 

BURNS    OF    THE    FACE,    INCLUDING    THE    EYELIDS 

SOME  of  these  cases  are  among  the  most  terrible  with  which  the  plastic  surgeon 
is  confronted.  By  a  counterbalancing  fortune  many  of  them  are  amenable 
to  surgical  treatment  to  a  remarkable  extent. 

Of  the  cases  of  facial  burns  that  have  come  to  me  for  treatment  all  had 
an  involvement  of  the  eyelids.  This  is  frequently  the  most  important  element 
of  the  disfigurement  and  disability.  In  other  cases,  it  is  the  only  disability 
remaining,  while  in  the  more  severe  cases  the  nose  is  burned  to  the  bone,  the 
mouth  is  contracted,  and  the  whole  of  the  facial  skin  has  been  replaced  by 
epithelialised  scar  tissue. 

The  main  causes  for  burns,  apart  from  the  ordinary  household  accidents, 
are,  in  their  order  of  frequency  and  occurrence,  as  follows : 

(1)  Cordite  Burns. — These  occur  in  the  burning  of  munition  dumps,  from 
backfires,  or  premature  bursts,  and  from  magazine  or  other  fire  in  naval  actions. 

The  recipient  of  this  class  of  burn  has  usually  the  power  to  run  away  from 
the  fire,  consequently  the  area  of  the  face  burned  is  not  constant.  In  the  more 
severe  forms  they  resemble  the  airman's  burn,  except  that,  there  being  no 
protecting  leather  helmet,  there  is  no  line  of  demarcation.  Sometimes  the 
upper  part  of  the  face  receives  the  full  brunt,  and,  in  others,  the  lower  part. 
Whether  the  neck  is  involved  depends  on  the  clothing  that  is  worn  at  the  time 
of  the  injury ;  thus,  an  ordinary  seaman,  whose  neck  is  exposed,  has  this  area 
burnt  in  addition  to  the  face,  while  a  muffler  and  a  tunic  will  afford  much 
protection  to  the  area  below  the  chin. 

In  contradistinction  to  the  airman,  whose  ears  are  seldom  burnt  by  fire, 
the  greater  majority  of  cordite  burns  present  a  lesion  of  the  pinna. 

(2)  Petrol  Burns. — These  are  caused  through  a  plane  catching  fire  in  the 
air  or  in  a  crash.     The  unfortunate  pilot  or  observer  usually  receives  ghastly 
burns  of  the  face  whilst  strapped  to  his  seat.     Should  he  survive,  a  typical 
airman's  burn  results,  which  may  be  described  as  being  limited  by  the  airman's 
helmet ;    and  usually  one  finds  a  definite  area  of  healthy  skin  commencing  from 
where  the  helmet  protects  the  face  and  head.     In  one  case,  the  burned  area 
stopped  just  below  the  chin,  where  the  helmet  commenced,  but  farther  down 
the  neck  two  kcloidal  scars  occurred  where  the  buckles  of  the  strap  had  become 
red-hot.     The  extraordinary  protection  which  this  leather  helmet  affords  the 
airman  leads  one  to  hope  that  some  protecting  device  against  such  terrible 
calamities  may  be  devised.     The  airman's  ears  usually  escape  destruction,  even 
in  severe  burns. 

(3)  Acid  Burns. — These  are  usually  the  result  of  a  factory  accident,  some 
caustic,  such  as  nitric  acid  or  sulphuric  acid,  being  splashed  on.  to  the  face. 


348  PLASTIC    SURGERY 

(4)  Burns  from  Flame-throrver.—One  case,  whose  origin  is  a  little  obscure, 
said  to  be  due  to  a  German  flame-thrower,  is  the  only  representative  of  this 
class  of  injury  which  has  come  under  the  author's  care. 

(5)  Electric  Burns.—  One  case  of  electric  burn  has  been  under  the  author's 
observation. 

In  regard  to  treatment,  this  should  be  divided  into  early,  intermediate, 
and  plastic. 

In  the  early  treatment  the  War  Office  No.  7,  substitute  for  ambrine,  would 
appear  to  give  as  good  results  as  any.  Picric  and  vaseline  dressings  would  not 
appear  to  give  results  markedly  inferior  to  paraffin.  McLeod  recommends  the 
use  of  stcarate  of  zinc  for  the  avoidance  of  limpet-like  crusts. 

The  rationale  of  all  this  treatment  would  appear  to  be  the  non-disturbance 
of  the  granulating  area  and  the  protection  of  the  wound  from  the  air. 

There  is  no  question  that  frequent  removal  of  dressings  which  adhere  to 
the  surface  is  distinctly  disadvantageous. 

Early  operative  treatment  is  indicated  in  the  form  of  skin-grafting  to  the 
eyelids  when  the  sight  is  in  danger,  or  when,  the  shock  of  the  burn  having  passed, 
a  definite  and  clean  raw  area  is  presented ;  but  no  experience  can  be  quoted  in 
support  of  this  opinion. 

In  regard  to  the  intermediate  treatment,  when  the  epithelium  is  regenerated, 
graduated  massage  is  of  great  value.  Insufficient  experience  prevents  a  decided 
opinion  on  the  value  of  electro-therapeutic  measures  at  this  stage,  but  radiant 
lic-at  and  ionisation  may  be  carefully  employed. 

At  what  stage  should  plastic  operations  be  commenced  ?  This  is  a  difficult 
question  to  answer,  as  the  time  appears  to  vary  in  different  cases.  The  author 
is  not  sure  that  any  plastic  operation  should  be  commenced  until  all  contraction 
has  ceased  and  the  scars  are  commencing  to  become  white.  This  is,  however, 
apart  from  any  consideration  of  plastics  on  the  eyelids,  which  may  have  to  be 
undertaken  for  the  protection  of  the  globe  on  short  notice  at  any  stage  of  the 
treatment. 

Another  consideration  which  favours  delay  is  the  difficulty  in  the  earlier 
stages  of  deciding  how  much  regeneration  of  the  epithelium  is  going  to  occur, 
and  consequently  how  much  of  the  face  it  is  necessary  to  replace  by  healthier 
skin. 

The  third,  or  plastic,  stage  having  arrived,  a  further  consideration  must 
be  taken  into  account.  Will  the  scar  so  materially  improve  under  X-ray  or 
radium  treatment  that  eventually  operation  is  only  indicated  for  parts  such  as 
eyelids,  eyebrows,  tip  of  the  nose,  or  angle  of  the  mouth  ?  The  author  feels 
that  for  severer  burns  the  complete  replacement  of  the  scar  tissue  by  healthy 


INJURIES    IN   THE    REGION    OF    THE    EYES  349 

skin  gives  a  better  cosmetic  result,  and  that  the  trend  of  plastic  surgery  to-day 
is  towards  a  more  radical  procedure.  Each  case,  however,  must  be  considered 
by  itself,  and  the  general  state  of  the  patient,  the  physical  and  mental  condition, 
must  be  weighed  in  the  balance.  There  is  no  doubt  that  in  one  very  severe 
burn  the  author  subjected  the  patient  to  too  great  a  shock. 


THE    OPERATIVE    TREATMENT    OF    BURNS 

As  has  been  pointed  out,  the  most  important  and  constant  factor  in  the 
facial  burn  is  the  cicatricial  ectropion  of  the  eyelids.  In  only  one  of  the  following 
cases  have  the  eyelids  escaped. 

For  this  disfiguring  disability  the  author's  operation  has  completely  super- 
seded previous  procedures.  In  only  two  of  the  series  of  ectropion  have  plastic 
flaps  been  used,  in  all  the  others  the  author's  method,  based  on  the  Esser  skin- 
graft,  has  been  employed.  A  typical  case  of  ectropion  from  fire  results  in 
the  destruction  of  the  skin  of  the  eyelid,  leaving  the  tarsal  plate  and  musculature 
intact.  In  the  worst  cases  the  latter  are  also  involved,  and  the  whole  of  the 
thickness,  even  of  the  lid,  may  be  destroyed.  In  two  of  our  cases  the  destruction 
went  farther  and  the  globe  was  destroyed. 

The  operation  for  the  typical  upper  eyelid  ectropion  or  epithelial  outlay 
is  as  follows  : 

Incision  is  made  just  above  the  ciliary  margin,  extending  right  across 
the  involved  area,  usually  from  canthus  to  canthus.  The  lower  flap  of  skin 
is  very  slightly  undermined,  to  give  a  free  edge.  The  upper  flap  is  freely  under- 
mined superficially  to  the  musculature,  until  the  lid-edge  drops  over  the  globe 
and  easily  reaches  the  lower  lid.  A  little  further  undercutting  is  continued, 
especially  laterally. 

Some  sterilised  dental  modelling  composition  is  now  moulded  into  the 
wound  and  allowed  to  set.  It  is  reduced  to  just  such  a  size  as  to  allow  skin 
approximation  over  it.  Its  shape  is  usually  one  that  can  be  compared  with 
the  scaphoid  bone  of  the  carpus,  minus  its  tubercle. 

The  anterior  surface  of  the  arm  is  now  prepared  for  skin-graft  by  thoroughly 
rubbing  with  aether  all  over  until  it  is  pink,  and  an  evenly  cut  thin  Thiersch 
graft  taken  of  such  a  size  as  can  be  Avrapped  round  the  mould  in  one  piece. 
The  skin-graft  has  to  be  placed  on  the  mould  with  its  raw  surface  outwards. 
Excess  of  graft  is  cut  off  with  sharp  scissors. 

In  the  process  of  wrapping  the  graft  round  the  mould  the  centre  of  the 
graft  is  laid  on  the  back  surface,  and  smoothed  out  over  the  borders  towards 
the  anterior  surface. 


PLASTIC    SURGERY 


inci&ion, 

JUST     ffBOVC      CIIMKV       OORDIR, 


TWIERSCH     GRAFT    in     POSITION 

SHOWING   SUTURES  THROUGH 

CVtUO    AMD   THIERSCM     GRAFT 


IMCIMON     ALONG    LIME    or    SUTURES 


FIG.  705. — Stages  in  the  epithelial  outlay. 


The  graft  and 
mould  arc  now  taken 
in  rat-tooth  forceps, 
the  skin  smoothed  out 
over  the  anterior  sur- 
face, and  the  excess  of 


HOLLOW,    SHOWING     RflW     «RE«      „]..•  m.nf4-  f,  ,,  f          n  f f 

TO     RECCIVt    THIERSCM     OR«I"T      SKin-gltlll  11  II. 


With  another  pair  of 
rat-tooth  forceps  the 
grip  is  changed  and 
the  first  pair  of  forceps 
removed.  While  this 
process,  which  is  some- 
what tricky,  is  being 
carried  out,  the  assis- 
tant should  pass  two 
horsehair  sutures  in 
readiness  to  be  tied 
from  one  skin  edge  to 
the  other.  The  loops 
of  these  stitches  are 
held  out  of  the  way, 
the  mould  and  graft 
are  slowly  lowered  in- 
to position,  and  the 
sutures  tightened  be- 
fore the  forceps  are 
removed.  If  after  one 
suture  is  tightened,  the 
forceps  are  removed, 
the  mould,  with  its 
graft,  is  very  liable  to 
slip  out  of  the  wound. 
The  further  suturing 
of  the  wound  is  carried 
out  with  horsehair,  and 
it  is  the  usual  practice, 
in  passing  the  needle, 
to  pick  up  the  graft, 
so  that  it  is  drawn 


UPPIR   »no  LOWER    Eoccs  or 
incision    aurunio  own   STENT 


EYELID         LOWERED         SHOWING 
OUTLINE    OF    THIE^SCH  vCRAFT 


D 


INJURIES   IN   THE   REGION   OF   THE   EYES  351 

between  the  raw  skin  edges.  The  knots  are  cut  short  after  being  securely  tied, 
and  the  wound  painted  with  tincture  of  benzoin. 

The  eyelid  now  assumes  a  position  of  more  marked  ectropion  than  prior 
to  the  operation,  and  a  protective  covering  to  the  exposed  conjunctiva  is 
necessary. 

After  Treatment. — The  eye  is  kept  clean  by  boric  lotions  and  the  wound 
kept  free  of  scabs,  the  mould  being  left  in  position  for  some  ten  to  twelve  days. 
As  a  rule,  by  the  end  of  this  time  part  of  the  mould  is  already  beginning  to  be 
extruded  through  the  original  incision,  and  its  complete  removal  is  carried  out 
by  following  along  the  incision  line  with  a  thin  pair  of  scissors.  Care  must 
be  taken  to  reopen  the  incision  right  to  its  full  limit — otherwise  the  ends  will 
be  pocketed.  The  eyelid  now  drops  to  below  its  normal  position,  and  the  skin- 
graft  is  invariably  to  be  found  completely  successful ;  there  are  only  some 
very  small  raw  edges,  due  to  the  reopening  of  the  incision,  which  remain  to 
epithelialise.  By  the  manoeuvre  of  picking  up  the  skin-graft  with  the  needle 
at  the  time  of  suture,  the  amount  of  this  raw  edge  is  very  materially  diminished. 

The  appearance  is  somewhat  bizarre  in  the  first  instance,  but  the  great 
hollow  produced  by  the  mould  rapidly  fills  and.  smooths  out.  In  the  upper 
lid  no  corrective  operations  are  usually  necessary,  but  in  the  lower  lid  the  lower 
margin  of  the  graft  where  it  joins  the  cheek  is  usually  very  thickened  and  con- 
spicuous, and  it  is  usually  found  necessary  to  excise  this  ridge  under  local 
anaesthesia  at  a  later  date. 

Common  Errors  of  the  Operation. — (1)  If  done  before  contraction  has  ceased, 
i.e.  too  soon  after  the  injury,  the  continuance  of  the  fibrotic  change  in  the  tissues 
beneath  the  graft  will  cause  a  shrinkage  of  it. 

(2)  The  area  grafted  is  frequently  insufficiently  wide. 

(3)  If  pieces  of  the  dental  composition  are  chipped  off  by  instruments,  as 
when  the  mould  is  trimmed  with  a  knife  instead  of  being  moulded  out  while 
hot,  or  when  the  mould  is  handled  with  rat-tooth  forceps  which  are  subsequently 
introduced  into  the  wound,  little  pieces  or  chips  of  the  composition  get  into 
the  wound,  and  act  as  a  source  of  irritation  or  infection. 

(4)  If  the  graft  is  not  carefully  wrapped  around  the  whole  of  the  mould 
some  of  the  latter  comes  in  contact  with  the  raw  surface  of  the  wound,  and  that 
part  is  found  not  to  be  grafted. 

(5)  An  excess  of  graft  tends  towards  the  formation  of  epithelial  debris, 
and   there   is    more   chance    of  an   infective   process    commencing.      Infection, 
however,  is  very  rare. 

The  lower  lid  is  treated  in  the  same  manner,  but  the  epicanthus  condition, 
which  is  frequently  present,  requires  a  separate  graft  which  cannot  be  buried. 
For  this  a  piece  of  modelling  composition  is  merely  held  down  by  stitches 


:1.v_>  PLASTIC    SURGERY 

retaining  the  graft  in  firm  apposition,  after  excision  of  the  scar  band  causing 
the  epieantltus.  The  results  are  very  nearly  perfect  as  far  as  the  upper  eyelid 
is  concerned,  both  aesthetically  and  functionally.  Those  of  the  lower  lid  are 
equally  successful  from  a  functional  point  of  view,  but  the  appearance  is  not 
so  neat  as  in  the  case  of  the  upper  lid.  Where,  in  addition  to  the  eyelid 
burn,  there  is  a  necessity  to  replace  the  whole  of  the  skin  of  the  face,  the 
author's  tube-pedicle  chest-flap  methods  are  indicated. 

The  principles  of  this  operation  arc  as  follows  : 

The  area  of  the  face  which  is  to  be  substituted  by  chest  skin  is  accurately 
measured  and  mapped  out  on  the  upper  part  of  the  chest.  To  this  area  are 
designed  long  neck  pedicles  usually  two  and  a  half  to  three  inches  in  breadth, 
and  left  attached  at  both  ends.  The  first  stage  consists  of  raising  the 
pedicles  and  tubing  them — that  is  to  say,  they  are  lifted  free  of  the  neck  and 
sewn  skin-edge  to  skin-edge,  into  a  tube.  The  pedicles  may  be  single  or 
double,  according  to  the  amount  of  facial  replacement  necessary.  The  raw 
area  of  the  neck  from  which  the  pedicles  have  been  lifted  is  usually  covered 
in  by  approximation  of  the  skin  edges  beneath  the  tube. 

The  second  stage  consists  in  raising  the  flap  of  skin  with  its  pedicle  or 
pedicles.  After  the  excision  of  the  burned  area  of  the  face  the  flap  is  passed 
up  over  the  chin  and  sutured  into  the  raw  area,  the  necessary  cuts  being  made 
in  it  for  mouth,  nose,  or  eyelid  apertures.  As  a  result  of  experience,  it  is 
found  better  to  include  part  of  the  flap  in  the  tubing,  and,  after  healing 
has  occurred,  following  the  second  stage,  the  pedicle  is  cut  from  its  original 
blood  supply,  reopened,  and  spread  over  the  remaining  portion  of  the  face. 
For  example,  it  is  possible  to  make  the  nose  portion  of  the  replacement 
with  an  extra  portion  of  the  tube  pedicle. 

No  pronouncement  can  be  made  as  to  the  length  and  breadth  of  the  pedicle, 
or  the  size  of  the  flap  that  can  be  utilised  with  success  ;  but  in  a  patient  already 
severely  shocked  the  raw  area  on  the  chest  is  an  additional  strain,  and  in  one 
case  of  the  author's,  where  the  flap  went  gangrenous  on  the  face,  the  double 
raw  areas  on  the  face  and  chest  were  so  severe  that  the  patient  succumbed 
three  weeks  after  operation.  Perhaps  also  the  mental  effect  of  the  failure 
contributed  to  the  poor  fellow's  demise.  In  a  later  case  of  an  airman's  burn, 
the  procedure  has  been  modified  by  the  introduction  of  a  new  principle— that 
of  shifting  the  upper  end  of  the  tube  pedicle  first.  The  various  steps  in  these 
large  laeial  replacements  are  reviewed  on  page  372.  The  illustrative  cases  are 
arranged  roughly  in  chronological  order  as  they  presented  themselves  for  treat- 
ment. This  is  done  to  indicate  the  process  of  the  evolution  of  the  treatment  to 
the  present,  dat  e.  :i  nd  i  t.  is  felt  that  if  they  had  been  presented  according  to  their  type 
of  injury  misunderstanding  of  certain  of  the  failures  might  possibly  eventuate. 


INJURIES    IN   THE   REGION   OF   THE   EYES 


.'353 


FIGS.  706  and  707. — Before  treatment  :  showing  ectropion  and  epicanthus  condition. 


: 


FIG.  708. — Immediately  after  removal  of  stents. 

Illustrative  cases  : 

CASE  645 

A  burn  as  a  result  of  this  officer's  machine 
catching  fire  in  action.  Although  the  whole 
face  has  been  burnt  the  skin  has  regenerated 
sufficiently  satisfactorily,  but  gives  one  the  im- 
pression of  a  face  that  has  suffered  from  small- 
pox. The  eyelids,  however,  were  the  seat  of 
ectropion,  complicated  by  much  scar  tissue  in 
the  inner  canthus  region,  simulating  epicanthus. 

Skin-grafts  by  the  "  outlay "  method  were 
applied  to  all  four  lids  at  the  same  operation,  and 
the  closure  obtained  therefrom  is  well  seen  in  the 
photograph  taken  immediately  after  the  removal 
of  the  moulds.  Later,  it  will  be  observed  that  the 
epicanthus  is  well  marked  on  the  left  side  espe- 
cially ;  this  was  dealt  with  by  further  skin-graft, 
held  in  position  by  stent  in  the  inner  canthus 
region ;  that  on  the  right  was  treated  by  ex- 
cision, which,  in  this  case,  appeared  to  be 
sufficient. 

In  regard  to  the  cure  of  epicanthus  by  this 
skin-grafting  method  where  this  is  combined  with 
a  lower  lid  ectropion,  I  think  it  is  the  best  pro- 
cedure to  carry  the  graft  of  the  lower  lid  round 
the  canthus  to  the  upper  lid. 

28 


Fia.  709. — Same  stage  later  ;  epicanthus  still  present. 


FiQ.  710. — After  further  graft  to  cure  epicanthus. 
Eyes  closed. 


PLASTIC    SURGERY 


CASE  124 

The  causative  agent  of  this  burn,  resulting  in  ectropkm  of  the  upper  and  lower  lids, 

Milplmrir  acid,  which  reached  the  eyelids  after  the  bursting  of  a  bottle  containing  it 
in  a  munition  factory. 

The  method  of  treatment  adopted  was  that  of  plastic  flaps,  and  three  operations  were 
required  before  a  sufficiently  satisfactory  result  was  obtained. 

The  first  operation,  as  illustrated  in  the  diagram,  is  somewhat  wrong  in  principle  as 
far  as  the  upper  lid  is  concerned,  as  the  gain  of  tissue  and  resuture  of  flaps  was  not  sufficiently 
definite.  Similarly,  the  "V  Y  "  operation  at  this  first  stage  was  insufficient  to  cure  the 
lower  lid  condition.  Fig.  712  represents  the  loss  of  tissue  in  the  upper  lid,  combined  with 
marked  ectropion  of  the  lower.  All^the  eyebrow  had  been  destroyed,  while  the  next  fig.,  713, 
shows  the  result  of  the  first  "operation. 

Following  this  operation  a  similar  flap  was  let  in  beneath  the  lower  lid  from  the  cheek, 
with  further,  but  still  inadequate,  improvement.  This  was  done  by  my  colleague,  Captain 
\Yilliains. 

A  month  later  the  lower  lid  was  further  improved  by  a  swinging  flap,  as  illustrated  in 
the  diagram. 

The  total  result  was  quite  satisfactory,  but  in  view  of  the  later  results,  a  quicker  and 
better  result  would  have  been  obtained  by  the  "  epithelial  outlay  "  method. 

To  complete  this  case  an  eyebrow  should  be  grafted  into  position.  A  pencilled-in 
eyebrow  is  illustrated. 


Fio.  71 1.-  Diagrams  of  the  three  operations  (see  text). 


INJURIES   IN   THE   REGION   OF   THE   EYES 


355 


Fio.  712. — Healed  condition. 


Fio.  713. — After  first  plastic. 


Fio.  714. — After  second  plastic. 


Fio.  715. — After  third  plastic.     (The  left  eyebrow 
is  pencilled.) 


356  PLASTIC    SURGERY 

CASE  338  ' 

This  poor  sailor  was  rendered  hideously  repulsive  and  well-nigh  incapacitated  by  terrible 
burns  received  in  the  battle  of  Jutland. 

How  a  man  can  survive  such  an  appalling  burn  is  difficult  to  imagine,  until  one  has 
met  one  of  these  survivors  from  fire,  and  realised  the  unquenchable  optimism  which  carries 
them  through  almost  anything. 

In  addition  to  the  total  facial  burn— viz.  destruction  of  the  nose,  lips,  eyelids  (not  the 
lid-edges)— the  ears  and  neck  were  burnt ;  and  the  hands  were  contracted  into  frightful 

deformities. 

I  had  only  seen  one  case  comparable  with  this,  and  that  had  not  yet  come  to  the  plastic 
stage ;  and  it  required  very  considerable  moral  courage  to  attempt  an  operation  such  as 
could  in  any  way  radically  cure  the  condition. 

The  process  of  thought  on  the  problem  led  one  to  decide  on  a  double-pcdiclcd  chest- 
flap,  the  pedicles  to  be  tubed  to  prevent  their  being  infected  or  exposed,  to  leave  attached 
to  these  pedicles  as  large  a  chest-flap  as  was  deemed  viable,  and  then  to  place  this  large 
flap  on  to  the  face,  excising  the  area  covered  by  it. 

It  was  hoped  to  swing  the  pedicles,  at  a  second  stage,  up  to  the  eye  region  for  the  cure 
of  the  ectropion  ;  but,  as  will  be  seen  by  the  progress  of  the  case,  a  much  better  eyelid 
operation  was,  in  the  meantime,  evolved  (see  Case  152),  and  this  left  the  pedicles  available 
for  other  purposes. 

The  big  flap  was  split  at  the  first  operation,  to  encircle  the  mouth,  the  lower  border 
of  this  incision  was  sutured  to  the  mucous  membrane  of  the  lower  lip,  while  the  upper  border 
was  carried  round  over  the  tip  of  the  nose  ;  but  the  upper  lip  was  not  replaced,  as  the  scar 
tissue  was  not  so  marked  there.  In  order  to  get  the  flap  free  from  tension,  it  was  necessary 
to  keep  the  neck  flexed,  and  an  apparatus,  in  plaster,  was  fixed  behind  the  patient's  head, 
so  that  this  position  might  be  kept. 

The  result  was  very  satisfactory  in  every  way,  except  in  that  portion  of  the  flap  which 
went  over  the  sharp  bridge  of  the  nose  :  at  this  spot  the  skin  was  at  its  greatest  tension, 
and  any  movement  of  the  head  and  neck  tended  to  tear  the  stitches  which  retained  the  flap 
on  the  nose.  It  was  soon  found  that  this  small  part  of  the  flap  began  to  slide  down  off  the 
nose,  and  this  movement  affected  its  blood  supply  and  gangrene  supervened.  No  other  un- 
toward result  occurred. 

In  regard  to  the  raw  area  of  the  chest  no  attempt  at  a  closure  was  made,  and  the  main 
line  of  treatment  carried  out  for  this  area  was  the  use  of  paraffin  No.  7.  At  one  stage  hot 
fomentations  were  also  applied  to  clean  the  surface. 

No  grafting  from  the  patient  was  attempted,  but  three  small  grafts  from  another  case 
were  laid  on  the  granulations,  without  success. 

The  next  stage  consisted  in  the  severance  of  the  left  pedicle  ;  this  was  done,  under 
novocaine,  thirteen  days  after  the  operation.  The  right  pedicle  was  severed  about  a  fortnight 
later. 

Three  months'  rest  was  given,  and  then  the  condition  was  as  shown  in  the  illustration. 
Attached  to  the  cheek  on  each  side  were  two  loose  tubed  pedicles  of  skin,  and  they 
w< -re  available  for  parts  other  than  the  eyelids,  owing  to  the  development,  in  the  meantime, 
of  the  "  outlay  "  method.  Therefore,  at  this  operation,  the  left  pedicle  was  partly  detached 
from  below  until  it  was  swung  round  to  form  a  flap  of  skin  sufficient  for  rhinoplasty,  the 
necessary  lining  being  provided  by  turning  some  of  the  epithclialised  scar  tissue  inwards. 
At  the  same  operation  both  upper  eyelids  were  treated  by  epithelial  "  outlays  "  in  the 
manner  described  at  the  commencement  of  this  section. 

Three  months  later  epithelial  "  outlays  "  were  applied  to  both  lower  lids,  the  secondary 

pedicle  of  the  rhinoplasty  divided  and  trimmed,  and  the  right  original  pedicle  opened  out 

and  spread  over  the  right  cheek,  where  it  was  sewn  after  the  necessary  excision  of  sear  tissue. 

A  long  rest  was  then  given  to  the  face,  but  in  the  interval  an  operation  was  performed 

on  the  hand. 

Four  months  after  the  last  face  operation,   cartilage  from  another  man  was  inserted 


INJURIES   IN   THE   REGION   OF   THE   EYES 


357 


FIG.  716. — Healed  condition. 


FIG.  717. — Flap  swung  to  face. 


-% 


*^5r     *^ 


FIG.  718. — Left  pedicle  divided. 


FIG.  719. —  Both  pedicles  divided. 


358 


PLASTIC    SURGERY 


Fio.  720. — Left  pedicle  swung  up  to  new 
attachment  near  nose. 


Fio.  721. — Lower  end  of  pedicle 
used  in  remaking  of  nose. 


FIG.  722. — After  epithelial  outlay  to  upper  lids  and  rhinoplasty. 
Not*  lymph-oedema  of  nose  at  this  stage. 


_VtW-|U 


Before  treatment.     Right  eye.  Before  treatment.     Left  eye. 

Flos.  723  and  724. — Showing  condition  of  ectropion. 


into  the  bridge  of  the 
nose  to  give  more  defini- 
tion and  prominence, 
while  trimming  and  al- 
terations were  made  in 
the  right  ala.  At  the 
same  operation  two 
whole-thickness  grafts 
from  the  scalp  were  taken 
to  make  eyebrows.  The 
author  has  found  that  a 
free  graft  from  the  edge 
of  the  hairy  scalp  above 
and  behind  the  ear  gives 
a  satisfactory  direction  of 
hairs  for  an  eyebrow 
graft.  These  grafts  took 
satisfactorily. 

Operation  notes : 

Injury,  May  1916. 

3.10.17.  Operation. 
— Masonic-collar  flap  with 
double-tubed  pedicles 
raised  from  the  chest  and 
grafted  on  to  the  face 
(author's  method).  See 
diagram. 

16.  10.  17.  —Left 
pedicle  divided  (novo- 
caine). 

1  .  11  .  17.  — Right 
pedicle  divided. 

19.2.18.— (1)  Left 
pedicle  undercut  and 
switched  to  nose.  (2) 
Epithelial  "  outlay  '  to 
both  upper  eyelids  for 
ectropion,  by  author's 
method. 

30  .  5  .  18.— (1)  Epi- 
thelial "  outlay  "  to  both 
lower  lids.  (2)  Trimming 
of  nose  pedicle.  (3)  The 
original  right  pedicle 
spread  across  the  right 
cheek  towards  the  ear. 

6.3.19.— (1)  Carti- 
lage (homologous)  to 
nose.  (2)  Trimming  of 
right  ala.  (3)  Whole- 
thickness  (Wolfe)  grofts 
from  scaly  to  form  eye- 
brows. 


INJURIES   IN   THE   REGION   OF   THE   EYES  359 

Right  eye  open.  Left  eye  open. 


FIG.  725. — Right  eye  soon  after  graft. 
The  edges  of  graft  are  too  abrupt. 


Closed.  Closed. 

FIGS.  726,  727,  728,  and  729.— After  excision  of  edges  of  grafts. 


FIGS.  730  and  731. — Present  condition.     Note  the  eyebrows  (free  grafts). 


3(JO  PLASTIC    SURGERY 


CASE  864 

This  naval  warrant  officer  was  very  severely  burned  in  the  battle  of  Jutland. 

A  most  interesting  record  was  presented  to  me  by  the  patient  in  the  form  of  a  photograph 

taken  of  his  face  soon  after  the  injury.     From  this  the  whole  face  would  appear  to  have 

been  charred,  and  it  is  indeed  remarkable  to  note  the  wonderful  progress  that  had  been 

obtained  during  the  healing  process.     Of  what  treatment  he  received,  and  by  whom,  the 

author  is  ignorant      The  condition  on  admission  is  shown  in  the  second  and  third  pictures. 

A  very  marked  cicatricial  ectropion  of  all  four  lids  was  the  most  disfiguring  feature  of 

the  case.     In  addition,  the  upper  part  of  the  face,  from  the  level  of  the  nose  to  the  forehead, 

was  a  mass  of  white,  waxy-looking  scar  tissue.     This  waxy  appearance  tended  to  accentuate 

the  glaring  redness  of  the  ectropion. 

It  was  decided  to  carry  out  a  complete  replacement  of  the  upper  half  of  the  face, 
and  for  that  purpose  a  chest-flap,  with  double  pedicles,  was  designed. 

In  order  to  avoid  gangrene  trouble  in  the  flap,  it  was  thought  advisable  to  tube  the 
pedicles  and  partly  undermine  the  flap  as  a  preliminary  stage,  in  contradistinction  to  the 
previous  case,  in  which  the  pedicles  were  tubed  at  the  time  of  operation.  As  the  flap  had 
to  be  carried  on  to  the  upper  part  of  the  face  the  base  of  the  pedicle  had  to  be  designed  at 
a  higher  level  on  the  neck,  and  it  was  in  consequence  not  very  broad,  being  only  about 
2j  inches. 

An  undoubted  mistake  was  made  at  this  first  stage  in  that  an  attempt  was  made  to 
stretch  the  part  of  the  flap  which  was  going  to  fit  over  the  prominence  of  the  nose.  Thus, 
the  central  portion  of  the  flap  proper  was  undermined,  and  a  piece  of  stent  (modelling 
composition)  was  moulded  into  the  form  of  the  nose  on  its  anterior  aspect,  and  to  fit  the 
chest  on  its  posterior. 

On  this  back  surface  Thiersch  grafts  were  laid,  so  that  the  raw  area,  caused  by  the 
elevation  of  the  flap,  might  be  partly  covered  in  by  epithelium.  No  skin-graft  was  laid 
over  the  anterior  aspect  of  the  mould,  and  consequently  infection  and  irritation  of  the 
under  surface  of  the  flap  followed. 

It  thus  happened  that  when  the  flap  was  raised  finally  from  the  chest  and  sown  into 
the  appropriate  area  of  the  face  a  very  marked  infection  of  the  whole  area  occurred,  and 
this,  obviously,  was  entirely  due  to  the  attempt  above  described  to  stretch  the  flap  prior 
to  it  being  put  on  the  face.  This  chest-flap  was  incised  in  two  places  on  each  side,  one  slit 
for  the  palpebral  fissure  and  another  through  which  the  remnants  of  the  eyebrows  were 
brought.  The  flap,  with  its  double  pedicle,  in  the  suppurating  stage,  is  well  illustrated 
by  the  photograph,  as  are  the  small  areas  of  the  flap  which  failed  to  live. 

After  the  return  of  the  pedicles  to  the  neck,  which  process  healed  by  first  intention, 
considerable  time  was  allowed  to  elapse  before  further  treatment  was  undertaken,  but 
during  the  interim  massage  was  administered. 

It  is  a  very  interesting  fact  that  this  patient  could  be  made  to  blush  into  his  new  flap 
at  the  time  when  the  pedicles  had  been  just  returned  to  the  neck.  Since  then,  not  only 
has  the  power  of  blushing  continued,  but  the  natural  lines  of  the  face  became— at  a  very 
early  date— evident,  and  an  accuracy  of  sensation  has  fully  developed. 

Corrective  operations,  for  enlarging  the  palpebral  fissure  and  for  excision  of  excess 
tissue,  were  subsequently  done  ;  but  it  became  apparent  that  the  flap,  as  grafted,  had  not 
entirely  cured  the  ectropion. 

Hy  this  time  the  author's  "epithelial  outlay"  operation  had  been  fully  established, 

kin-grafts  in  the  areas  indicated  in  the  diagram  were  successfully  carried  out. 
\N  ith  the  addition  of  artificial  eyebrows  a  presentable  appearance  was  obtained,  while 
the  ectropion  was  cured. 

The  latest  news  from  this  patient,  who  has  returned  to  duty,  is  that  he  has  been  passed 
by  the  naval  authorities  medically  fit  for  service. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


861 


• 


Fio.  732. — Soon  after  facial  burn. 


Flo.  733. — On  admission.     Marked  ectropion,  and 
scarring  of  forehead. 


Operation  notes  of  this  case  : 

12.11.17.  Condition. — Severe  cordite  burns,  face  now  healed,  affecting  mostly  upper 
part  of  the  face.  Loss  of  both  lower  lids.  Loss  of  both  upper  lids,  with  marked  ectropion. 
Remains  of  the  edge  of  the  lids,  and  some  eyelashes,  are  present.  Forehead  and  eyebrows 
burnt  and  scarred.  Slight  remnant  of  each  eyebrow  remains.  Nose,  fleshy  part,  burnt 
off,  and  a  thin  white  ivory  scar  remains.  A  similar  white  scarring  below  and  external  to 
each  eye. 

12.11.17.   Operation.— Chest-flap,  fig.    734. 

Note. — Central  dotted  portion  was  the  area  raised  by  the  stent  mould,  the  under 
surface  of  which  carried  skin-graft  for  the  chest- wall. 

18.11.17. — The  stent  holding  in  the  graft  caused  trouble,  too  much  tension  over 
the  tip  of  nose,  stitches  had  to  be  cut,  collection  of  pus,  and  temperature  until  removal  of 
stent. 

30.11.17.  Operation  (second  stage). — Transference  of  flap  to  face  after  excision  of  all 
the  epithelialised  scar  tissue,  from  the  level  of  the  tip  of  the  nose  to  \  in.  above  the  eyebrows. 
The  blood  supply  of  this  flap  was  noted  to  be  fairly  satisfactory  at  the  operation. 

13.12.17.  Progress. — Very  considerable  suppuration  followed  operation.  The  flap 
was  almost  floating  in  pus  at  one  time,  and  drainage  tubes  had  been  inserted  at  several 
places.  Small  area  of  gangrene  occurred  over  the  tip  of  the  nose  and  above  the  eyebrows. 

8.1.18.  Operation  (third  stage). — Pedicles  returned  to  the  neck.  A  free  blush  into  the 
new  flap  is  to  be  observed. 

9.5.18.  Operation. — Palpebral  fissures  widened.  Excision  of  scar  tissue  at  margin 
of  flap. 

24.7.18.   Operation. — Three  epithelial  "outlays."     See  diagram. 


302 


PLASTIC    SURGERY 


FIGS.  734  and  735.— To  show  tubing  of  pedicles  and  undercutting  of  flap. 


Fio.  736.— Flap  in  suppurating  stage  (see  text). 


737.— Pedicles  returned.     Ectropion  persisting. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


363 


FIG.  738. — Showing  areas  treated  by  outlay. 


FIG.  739. —  On  discharge.      Ectropion  relieved. 


364  PLASTIC    SURGERY 

CASE  388 

There  was  a  very  pathetic  sequel  to  this  most  terrible  case,  in  that  the  patient  after 
having  survived  the  ordeal  of  the  burn,  lived  and  regained  a  certain  amount  of  strength 
twi-nty  months  after  the  injury,  died  as  a  late  result  of  a  plastic  operation. 

He  was  admitted  to  my  care  fifteen  months  after  the  injury.  The  picture  of  the  con- 
dition shows  the  injury  remarkably  well.  The  colour  of  the  scar  tissue,  which  was  an  ugly 
red  made  the  appearance  more  ghastly  than  the  illustration  portrays.  In  addition  to  the 
left  eye  being  burned  and  to  all  the  other  destruction  in  evidence,  the  right  eye  was  prac- 
ticallv  blind,  as  a  result  of  staphyloma  of  the  cornea. 

He  had  received  most  painstaking  and  careful  treatment  prior  to  his  admission  to  my 
department ;  included  amongst  other  things,  a  skin-graft  to  the  upper  lid  had  been  done, 
which  undoubtedly  saved  the  remaining  sight. 

In  view  of  the  success  of  the  two  cases  of  burns  described  before  this  one,  it  was  decided 
to  replace  the  whole  skin  of  the  face  by  a  chest-flap.  The  flap  was  designed  larger  than 
those  for  the  two  previous  cases,  and  was  of  sufficient  size  to  cover  the  whole  face.  As  a 
preliminary,  the  neck  pedicles  were  tubed.  At  this  stage  also  incisions  were  made  into  the 
area  of  ski'n  which  was  going  to  form  the  face,  and  they  represented  the  slits  necessary  to 
make  the  mouth,  nostrils,  and  palpebral  fissures.  These  incisions  are  distinguishable  as 
scars  in  the  illustration,  fig.  742,  and  it  should  be  noted  that  they  became  keloidal  scars  and 
did  not  heal  up  at  all  quickly ;  they  were  sewn  up  with  horsehair. 

After  the  pedicles  had  been  made,  a  rest  of  two  and  a  half  months  was  given,  as  the 
patient  was  obviously  slow  in  recovery,  both  generally  and  locally,  after  which  it  had  to  be 
decided  whether  to  give  this  unfortunate  airman  a  further  year's  rest  or  whether  to  carry 
on  with  the  procedure,  knowing  that  the  latter  might  not  succeed. 

The  patient  had  got  used  to  a  considerable  amount  of  morphia  and  a  certain  amount 
of  stimulants  since  the  time  of  injury,  which  was  certainly  derogatory  as  far  as  his  treatment 
was  concerned.  Having  pinned  his  faith  on  the  result  of  the  forthcoming  operation,  he 
was  bitterly  disappointed  and  exceedingly  depressed  at  the  thought  of  having  to  wait  another 
long  period,  and  it  was  feared  that  he  would  not  wait  so  long. 

Owing  to  the  generally  poor  healing  powers  of  the  patient,  it  was  decided  to  add  two 
more  pedicles  to  the  flap,  the  design  of  which  is  visible  in  the  illustrations.  The  operation 
was  duly  carried  out,  and  was  an  exceedingly  tedious  one.  Skin  to  cover  the  raw  area  of 
the  chest  was  taken  from  a  volunteer,  which  part  of  the  operation  was  very  kindly 
undertaken  for  me  by  Lieutenant-Colonel  H.  S.  Newland,  D.S.O.,  A.A.M.C. 

The  appearance  at  the  end  of  the  operation  was  pleasing,  and  the  blood  supply  to  the 
flap  seemed  sufficient  to  ensure  its  persistence.  When  the  patient  had  recovered  from  the 
shock  of  the  operation  and  the  long  ana>sthetic  there  was,  quite  obviously,  good  blood 
supply  in  the  flap.  Next  day,  however,  the  patient  was  considerably  collapsed,  and  the 
flap  itself  suffered  in  the  general  depression  of  circulation,  and  in  thirty-six  hours  became 
blue.  From  then  onwards  there  was  a  steady  progress  of  the  gangrene,  which  went  from 
dry  to  moist  over  all  the  flap,  except  a  small  portion  of  each  pedicle.  The  skin-graft  to 
the  chest  failed  to  take,  and  despite  the  most  unremitting  care  of  the  sister  in  charge,  and 
Captain  R.  Montgomery,  R.A.M.C.,  the  patient  gradually  sank  and  died  twenty-four  days 
after  the  operation.  Both  the  chest  area  and  that  of  the  denuded  face  became  infected, 
and  towards  the  end  mctastatic  abscesses  occurred  in  various  regions. 

In  reviewing  the  case,  the  attempt  to  reconstruct  the  whole  face  is  a  procedure  which 
is  obviously  justifiable,  and  it  would,  in  a  more  reposed  patient,  have  succeeded.  It 
is  possible  that,  had  the  author  taken  a  very  firm  attitude,  and  could  he  have  persuaded 
the  patient  to  wait  a  year,  the  operation,  as  planned,  would  have  had  more  chance  of  success. 
The  author  is  convinced  that  the  operation  should  have  been  done  in  piecemeal — perhaps 
that  one  <|n;irtrr  only  of  the  face  should  have  been  done  at  a  time.  By  this  means  a  very 
presentable  result  mi^ht  have  been  gained  ;  but  it  obviously  would  not  have  been  as  good 
as  the  single  replacement  method,  and  the  author  feels  that  his  desire  to  obtain  a  perfect 
result  somewhat  over-rode  his  surgical  judgment  of  the  general  condition  of  the  patient. 


INJURIES   IN    THE   REGION   OF   THE   EYES 


365 


The  operation  took  much  longer  than  was  anticipated,  the  shock  was  greater,  and  with  the 
failure  of  the  skin  to  take  on  the  chest  and  of  the  flap  to  live  on  the  face,  the  severity  of 
the  operation  was  enormously  increased.  One  could  have  wished  that  this  brave  fellow 
had  had  a  happier  death. 


Fid.  740. — Healed  condition. 


FIG.  741. — First  pair  of  pedicles  tubed. 


FIG.  742. — Flap  and  second  pair  of  pedicles  out- 
lined.    Note  keloidal  condition  of  scars. 


FIG.  743. — Flap  swung  to  face.     (See  text.) 


3(JG 


PLASTIC    SURGERY 


CASE  152 

This  gunner  received,  on  22.10.16,  a  cordite  burn,  and  was  admitted  three  months 
later,  when  the  condition  was  still  unhealed. 

After  another  two  months,  the  first  plastic  was  performed,  and  this  consisted  in  the 
excision  of  scar  tissue  across  the  root  of  the  nose  anil  the  left  inner  canthus  region  ;  the 
raw  area  thereby  caused  being  filled  in  by  two  flaps.  The  main  one  was  brought  down 
from  the  forehead  and  laid  across  the  root  of  the  nose  and  left  inner  canthus  region  :  the 
subsidiary  flap  on  the  right  side  was  made  to  advance  to  complete  the  right  aspect  of  the 
nose. 

The  result  of  this  operation  was  unsatisfactory,  as  an  acute  infection  was  lit  up  by 
the  excision  of  the  scar  and  no  primary  union  occurred. 

Next,  a  whole-thickness  free  graft  (Wolfe)  was  attempted  in  the  right  lower  lid,  below 
the  eanthus  ;  but  there  was  no  definite  evidence  that  any  benefit  had  accrued. 

Before  the  next  stage  the  author  had  been  doing  the  Esser  inlay  for  entropic  conditions, 
and  it  occurred  to  him  that  the  process  might  be  reversed  and  the  principle  applied  to  ectropic 
conditions.  To  distinguish  the  latter  from  the  Esser  inlay  the  name  "  epithelial  outlay  " 
was  given  it ;  and  the  operation  is  described  on  p.  350. 

As  regards  the  upper  lid,  the  result  was  all  that  could  be  wished,  but  a  certain  amount 
of  infection  of  the  lower  left  lid  occurred,  and  the  area  grafted  has  not  blended  with  the 
surrounding  tissues. 

Operation  notes  : 

Operation. — Excision  of  scar  and  flap  operation  as  per  diagram. 

4.6.17.  Operation. — For  restoration  of  right  lower  eyelid.  Excision  of  scar  and 
replacement  of  lid  to  normal  level.  A  triangular  piece  of  skin  from  the  chest,  denuded  of 
fat  (size,  roughly,  f  in.  each  side),  was  inserted  and  stitched  in. 

23.11.17. — Result  of  free  graft  was  problematical.     Slight  ectropion  of  lid. 

General  condition. — Great  improvement  in  skin  under  massage,  still  ectropion  of  lower 
lids  and  marked 'shortening  of  left  upper  lid. 

23.11.17.  Operation.  -To  cure  ectropion  condition  all  three  lids  by  reverse  epithelial 
inlay  method,  or  epithelial  outlay. 

1.  Incision  over  left  upper  lid  widened  and  deepened,  until  lid  dropped  into  position. 
Cavity  deepened  further,  and  an  impression  of  this  cavity  taken  in  stent,  covered  with 
Thiersch  graft,  and  sewn  up. 

2  and  3.  Similar  procedure  in  both  lower  lids— inner  ocular  angles.  External  in- 
cision reopened  and  stent  removed. 
This  allowed  the  upper  lid  to  fall 
down  into  position. 

Later  :  The  left  lower  lid  stent 
was  extruded  and  a  little  suppur- 
ation occurred.  The  right  side  was 
taken  out  on  tenth  day. 


\ 


' 


Fio.  744. — Excision  of  scar  and  plastic 


Fio.  745. — AVolfe  graft  to  relieve  ectropion  right 
lower  lid. 


INJURIES   IN   THE    REGION   OF   THE   EYES  367 


Fio.  746. — On  admission. 


FIG.  747. — After  first  plastic. 


FIG  748. — After  outlays. 


FIG.  749. — Final :  Showing  relief  of  ectropion. 


308  PLASTIC    SURGERY 


CASE  513 

This  is  an  excellent  example  of  the  use  of  the  tube-pedicle  flap  to  replace  a  portion  of 
the  face. 

The  burn,  on  this  occasion,  was  due  to  the  premature  burst  of  a  shell  in  action. 

Apart  from  the  eyelids,  which  were  the  seat  of  cicatricial  ectropion,  the  whole  face 
and  neck  were  generally  burnt,  but  had  recovered  with  slight  disfigurement  of  the  skin, 
except  in  the  region  along  the  line  of  the  mandible  ;  here  was  marked,  dense,  keloidal  scar 
extending  from  one  ear  to  the  other  along  the  mandibular  contour,  considerably  more 
marked  on  the  left. 

The  first  and  most  important  part  of  the  treatment  consisted  in  providing  the  cornea 
with  a  covering,  and,  in  order  to  cure  the  ectropion,  epithelial  outlays  were  carried  out  for 
both  upper  lids.  At  the  same  time  the  right  mandibular  scar  was  excised,  and  the  skin 
merely  approximated. 

The  early  results  of  the  epithelial  graft  of  the  eyelids  were  satisfactory,  but  a  certain 
amount  of  contraction  subsequently  occurred,  not  sufficient,  however,  to  cause  discomfort 
to  the  patient. 

At  the  next  stage,  undertaken  five  months  later,  a  flap  was  designed  on  the  left  side 
with  the  base  in  the  posterior  triangle  of  the  neck.  Parallel  cuts  were  carried  downwards 
ami  inwards  over  the  anterior  chest  wall,  separated  by  an  interval  of  3|  inches,  the  width 
of  the  flap. 

The  flap  was  raised  and  sewn  into  a  tube  in  the  usual  manner,  by  sewing  skin  edge 
to  edge  on  its  under  surface.  The  area  from  which  the  flap  was  raised  was  covered  in  by 
widely  undercutting  the  skin  margin  and  approximating  them  beneath  the  tube.  The 
result  was  satisfactory. 

It  is  to  be  noted  that  in  order  to  get  the  closure  more  easily,  the  skin  over  the  posterior 
triangle  was  advanced  up  to  the  clavicle  and  held  there  by  deep  catgut  sutures  passed 
through  the  periosteum  of  that  bone.  Twenty-one  days  later  the  lower  end  of  the  flap 
was  detached,  partially  opened,  and  grafted  into  the  chin  area.  The  necessary  amount  of 
scar  tissue  was  excised  to  receive  it. 

Two  months  afterwards  the  upper  end  of  the  tube  flap  was  detached,  the  rest  of  the 
scar  tissue  extending  up  to  the  ear  was  excised,  the  tube  opened,  and  the  flap  spread  across 
the  raw  area.  The  upper  extremity  of  the  flap  was  split,  one  portion  going  over  the  front 
of  the  ear  and  one  behind.  This  was  done  in  order  to  free  the  pinna,  which  was  involved 
in  the  general  scar  contraction.  It  should  be  noted  that  the  blood  supply  to  this  flap  was 
perfectly  satisfactory,  both  at  the  first  and  second  shifts,  but  of  the  two  the  second  shift 
appeared  more  safe  than  the  first.  If  this  indication  is  true,  it  would  indicate  that  the 
new  blood  supply  to  the  flap  from  the  chin  region  was  of  a  more  vigorous  nature  than  that 
which  it  received  from  its  original  base  in  the  neck.  As  a  corollary,  if  this  hypothesis  is 
true,  the  radical  procedure  of  shifting  the  base  of  the  pedicle  first  would  be  indicated.  This 
has,  in  a  later  ease  of  the  author's,  been  undertaken,  but  there  are  not  sufficient  data  to 
establish  the  principle. 

Great  relief  lias  been  experienced  by  this  patient  in  the  additional  freedom  of  movement 
by  the  excision  of  the  scar. 

*.•_'.  is.  ()/iiriiti<m. — Epithelial  outlays,  both  upper  eyelids  for  ectropion  and  excision 
of  riylit  mandibular  scar  extending  up  as'far  as  the  tip. 

AY.s ult.— Almost,   complete  closure  of  palpebral  fissure.     Some  subsequent   retraction 
liiis  occurred,  caused  by  amount  of  scar  tissue  present. 
1  s .  .' .  1 8 .    O/in-dtion.  —Removal  of  stcnt. 

25.7. 18.   ()/>,  ml  ion.—  A  flap  was  prepared  from  left  side  of  neck  and  left  pectoral  region 

for  transference  tot  he  mandibular  region  to  replace  scar  tissue.     Width  of  flap  3|  in.,  parallel 

ut,  the  outer  cut  emitiimcd  farther  down  the  chest  than  the  inner  base  of  flap,  in  posterior 

triangle  of  left  neck  at  the  anterior  border  of  the  trapezius.     After  undercutting  this  flap 

it   was  \,  is    can  fully  tubed. 


INJURIES   IN   THE   REGION   OF  THE   EYES 


369 


V 

».r :  ii     m   /  j.m 

k.     ^^^^^^^^^^^^          '       J^^H 

?V         -~«a  /• 


Fios.  750  and  751. — On  admission. 


Fio.  752. — Showing  area  excised  and  preparation  of  tube  pedicle. 


24 


370 


PLASTIC    SURGERY 


Hy  extensive  undercutting  of  the  remaining  skin  and  suitable  advancements,  it  was 
found  possible  to  get  a  complete  closure  under  the  pedicle.  (Note  that  a  special  advance- 
ment of  the  upper  end  to  the  clavicle  helped  this  considerably.)  First  of  all  a  number  of 
deep  relaxation  catgut  sutures  were  inserted.  Two  of  these  united  the  trapezius  and  sterno- 
mastoid  muscle  to  the  periosteum  of  the  clavicle  to  obliterate  the  usual  supra-clavicular 
hollow.  Relaxation  sutures  and  buttons  were  also  used.  Drainage  tube  from  clavicle 
region.  Result — satisfactory.  Primary  union. 

3.8.18. — To  transplant  the  pedicle  flap  to  take  the  place  of  the  scar  tissue  on  neck 
and  chin.  The  scars  on  neck  and  chin  were  excised,  as  shown  in  photograph.  The 
skin  retracted  about  1  in.  The  portion  of  skin  marked  "  A  "  was  retained,  freed,  and 
swung  to  the  left  with  its  base  attached  upwards.  The  pedicle  of  the  tube-flap  was  separ- 
ated at  its  extremity,  and  its  outer  half  opened  up  and  sutured  to  the  raw  area  made  by 
the  excision  of  the  scar.  At  the  inner  canthus  of  each  eye  a  small  plastic  was  performed 
to  correct  the  tendency  to  almond  eyes. 


Fio.  753.— Pedicle  tubed. 


Fio.  754. — Chest-flap  swung  to  chin. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


371 


Side  view. 


Front  view. 
Fios.  755  and  756.— After  plastic. 


372  PLASTIC    SURGERY 

CASE  1002 

Case  1002  was   almost   a   typical  "  airman's  burn  "—that  is  to  say,  serious  damage 
is  limited  by  the  airman's  helmet  to  the  face  ;   the  upper  half  of  forehead,  and  the  ears  and 
neighbouring  strip  of  cheek  escape.     There  was,  in  addition,  a  less  serious  bum  of  the 
fronto-parietal  region. 

The  resulting  keloidal  scar  had  led  to  severe  ectropion,  distortion  of  alse  ot  the  nose, 
and  microstoma,  barely  admitting  a  teaspoon. 

Attempts  had  been  made  elsewhere  to  skin-graft  portions  of  the  face,  and  the  appearance 
on  admission  is  shown  in  fig.  757  (22.8.18). 

With  a  view  to  softening  the  scar  and  improving  its  blood  supply,  a  thorough  course 
of  X-ray  and  diathermic  treatment  was  undertaken.  This  led  to  a  definite  improvement, 
and  by  "27. 3. 19  the  prospect  of  operation  appeared  favourable. 

This  case  is  important,  as  being  the  first  in  which  a  postauricular  flap  was  used  ;  and 
it  may  be  of  interest,  at  the  risk  of  some  repetition,  to  insert  here  the  stages  by  which  the 
decision  to  use  it  was  arrived  at : 

In  the  first  instance  (Case  338)  a  "  Masonic  collar  "  flap  was  taken  from  the  chest,  on 
two  pedicles  which  were  tubed  at  the  time  of  the  operation. 

Though  successful,  it  was  considered  that  in  subjects  of  inferior  physique  the  demand 
made  on  the  blood  supply  might  prove  too  great. 

Accordingly,  in  Case  364— another  Masonic  collar-flap — the  pedicles  were  tubed 
first,  and  the  flap  turned  up  after  three  weeks'  interval. 

In  Case  513,  a  unilateral  area  from  chin  to  left  ear  required  covering.  After  tubing, 
a  long  single-pedicle  flap  was  turned  up  from  the  chest  and  applied  to  an  area,  rawed  for 
its  reception,  upon  the  chin.  Grave  doubts  were  entertained  as  to  its  viability,  at  this 
stage ;  but  in  the  second  stage— the  severance  from  its  original  base,  and  the  spreading 
of  the  opened-out  pedicle  upon  the  cheek — there  was  never  a  moment's  misgiving. 
Apparently  the  introduction  of  a  new  blood  supply  into  tissue  (especially  when  it  is  grafted 
upon  the  face,  the  most  vascular  site  of  all)  has  a  powerful  stimulatory  effect. 

In  view  of  this  experience  it  was  decided  (Case  565)  to  lessen  the  demands  on  the 
pedicle  by  shifting  its  upper  end  (its  future  base)  closer  to  the  first  objective,  to  begin  with. 

After  an  interval  of  three  weeks  for  its  establishment  in  its  new  situation,  its  lower 
end  was  brought  up  to  the  chin.  The  result  of  this  manoeuvre  was  highly  satisfactory  ; 
when  a  firm  hold  had  been  taken  upon  the  chin,  the  original  base,  plus  an  extra  area 
from  the  posterior  triangle  of  the  neck,  was  swung  up  to  the  nose,  and  after  a  suitable  interval 
the  pedicle  was  opened  out  and  spread  upon  the  cheek. 

To  return  now  to  Case  1002.  As  the  preliminary  shifting  of  the  upper  end  of  the  tube- 
pedicle  seemed  to  be  so  helpful  in  the  last  case,  it  was  decided  here  to  adopt  a  similar  plan. 
While  considering  the  site  of  this  preliminary  shift,  the  author  realised  the  futility  of 
being  wedded  to  flaps  from  below  the  face,  the  bases  of  which  would  always  need  shifting. 
Why  not  go  higher  at  once  ? 

It  happened  that  in  this  case  the  area  of  hair-free  skin  behind  the  ear  was  relatively 
wide,  and,  further,  was  freckled  in  a  manner  similar  to  what  remained  of  normal  face 
skin  ;  and  so  a  post-aural  flap  was  decided  upon.  (It  should  be  noted  that  this  flap  is  not 
always  available,  nor,  when  available,  is  it  always  suitable.) 

To  obtain  sufficient  width,  the  skin  over  the  posterior  surface  of  the  pinna  was  removed 
in  continuity  with  that  over  the  mastoid,  and  the  width  was  still  further  increased  by  the 
inclusion  of  a  small  area  of  hairy  scalp — a  slight  disability,  but  of  no  great  import  in  a  light- 
skinned  subject. 

Having  shifted  the  base  of  the  flap  first,  the  intention  was  to  tube  a  portion  of  the  neck 
and  chest  if  necessary,  and  then  swing  this  tube  up  to  complete  the  facial  restoration,  the 
final  blood  supply  IK  ing  through  the  new  cheeks. 

On  the  left  side,  the  scar  tissue  over  the  cheek  was  excised  (the  dissection  in  places 
going  very  deep),  and  the  shape  and  size  of  the  flap  were  nicely  adjusted  to  fit  this  area. 


INJURIES   IN  THE   REGION   OF  THE  EYES 


373 


The  requisite  length  of  pedicle  was  carefully  gauged,  but  the  behaviour  of  flaps  is  not 
always  susceptible  of  mathematical  analysis,  and  the  colour  of  the  flap  was  anxiously  watched 
during  the  process  of  dissection.  When  swung  forward  and  sutured  to  its  new  position, 
the  flap  turned  very  blue,  especially  that  portion  from  the  pinna,  and  hot  saline  dressings 
were  applied  every  two  hours,  beginning  with  the  post-operative  dressing. 

After  twenty-four  hours  the  flap  appeared  to  be  going  gangrenous  ;  but  a  remarkable 
recovery  occurred,  and  by  the  third  day  anxiety  ceased.  Only  a  small  piece,  from  the 
hairy  scalp,  failed  to  take. 

Thiersch  grafts,  under  moulded  stent,  were  applied  to  the  raw  area  behind  the  ear,  but 
with  small  success,  owing  to  insufficient  fixation  of  the  mould. 

On  the  right  side  the  proceeding  was  similar,  and  the  flap  went  through  the  same  pre- 
carious period.  Here  the  scar  was  dissected  from  the  face  in  one  piece,  and  was  applied 
as  a  graft  to  the  raw  area  behind  the  ear.  After  removal  of  slough,  it  was  found  that 
valuable  islands  of  epithelium  had  become  adherent,  considerably  assisting  the  healing 
process. 

On  these  healthy  and  natural-looking  new  cheeks,  flaps  can  now  be  swung  up  from 
either  side  of  the  neck  for  the  nose  and  chin.  The  eyelids  will  be  dealt  with  by  epithelial 
outlays. 

Note. — These  flaps  are  similar  to  the  one  employed  in  Case  No.  215,  p.  72,  in  the  section 
on  cheeks. 


FIGS.  757  and  758. —  On  admission. 


PLASTIC    SURGERY 


Fio.  759. —  Case  1002.     Excision  of  scar  and  flap  outlined. 


l''n;s.  71)0  and  761. — Restoration  of  both  cheeks  from  post-aural  region. 


INJURIES   IN   THE   REGION   OF   THE   EYES 


375 


CASE  565 

It  is  occasionally  noticed  that  these  epi- 
thelial grafts  suffer  from  a  subsequent  con- 
traction, which  would  appear  to  be  due  to  the 
fibrotic  process  continuing  in  the  bed  on  which 
the  graft  is  raised — in  other  words,  the  graft- 
ing is  probably  done  too  soon.  Disappointing 
results  are  therefore  to  be  expected  in  very 
severe  burns,  when  the  scar-tissue  formation 
is  still  active.  Nevertheless,  in  order  to  get 
the  eye  protected  by  a  covering,  it  is  a  correct 
procedure  to  perform  one  of  these  graft 
operations.  It  is  easy  to  do  another  at  a 
later  date,  and  allowance  should  be  made  for 
contraction. 

In  case  No.  565  an  excellent  skin-graft 
to  the  right  lower  lid  and  inner  canthus  region 
resulted  in  'a  disappointment  and  a  shrinking 
to  less  than  half  its  area.  This  would  appear 
to  be  due  to  the  causes  above  mentioned. 

Photographs  are  attached  illustrating  the 
condition  and  area  of  the  graft  shortly  after 
the  removal  of  the  mould,  while  that  of  three 
months  later  shows  the  contraction  that  has 
occurred. 

This  case  has  been  complicated  by  ulcers 
on  the  cornea,  rendering  immediate  procedure 
to  obtain  a  covering  advisable. 


FIG.  762. — On  admission. 


Fio.  7G3. — Shortly  after  outlay  to 
right  upper  lid. 


FIG.  764. — Three  months  later. 
The  outlay  has  contracted. 


The  next  three  cases  are  of  burns,  the  interest  of  which  lies  in  the 
repair  of  the  eyelids,  by  the  epithelial  outlay  operation.  There  is  nothing 
special  to  describe  about  the  operations,  as  they  conform,  in  practically  every 
detail,  to  the  type  operation  in  the  beginning  of  the  chapter. 


37G 


PLASTIC    SURGERY 
CASE  557 


Epithelial  outlay  operation  for  eyelids,  performed  on  16.5.18,  fourteen  months  after 
the  result  of  the  burn.  Photographs  illustrating  the  eyes,  closed  and  open,  before  and 
after  treatment,  require  no  description. 

Right  eye. 
Open. 


Closed. 


FIGS.  765  and  766. — Before  treatment. 


FI03.  767  and  768.— Soon  after  operation. 


Flos.  769  and  7 70. —Final  result. 


INJURIES   IN   THE    REGION    OF   THE   EYES 


377 


CASE  633 

Case  633  shows  the  result  of  burns  in  action,  received  on  board  one  of  H.M.  monitors. 
The  nose  and  right  ear  were  also  burned  and  have  not  yet  been  treated ;  but  the  ectropion 
of  the  eyelids  has  been  cured  by  the  epithelial  outlay. 

The  little  fold  observable  in  the  open  position  after  operation  could  be  easily  rectified 
by  simple  excision,  without  interfering  with  the  result. 


Closed. 


Right  eye. 


Open. 


FIGS.  771  and  772. — Before  treatment. 


FIQS  773  and  774. — After  treatment. 


378  PLASTIC    SURGERY 

CASE  386 

This  was  the  patient  who  stated  that  he  had  been  burned  by  a  German  flame-thrower. 
But,  as  the  accuracy  of  this  information  is  not  determined,  the  causative  agent  is 
regarded  as  unknown.  From  its  appearance,  one  would  judge  it  to  be  an  acid  burn. 

The  main  area  affected  was  the  chin,  which  was  the  seat  of  a  large  keloidal  scar.  Ex- 
tending from  the  extremity  of  this  were  two  scar  lines  running  in  to  the  nasolabial  fold. 
Tin-  lower  lip  was  markedly  ectropic,  the  mucous  membrane  red,  glazed  and  studded,  with 
mucous  vesicles.  Below  the  chin  scar  the  burn  extended  down  the  neck  and  chest,  gradually 
diminishing  in  severity.  On  the  face  area  involved  the  burn  seems  to  have  affected  certain 
spots  much  more  than  others,  and  often  an  island  of  healthy  skin  would  be  lying  at  the 
bottom  of  a  pit,  the  walls  of  which  were  composed  of  dense  keloid. 

Treatment. — The  deep  portion  in  the  left  nasolabial  furrow  was  first  excised  and  the 
skin  approximated.  Then  the  mass  of  the  keloid  on  the  chin  was  freely  removed,  together 
with  a  redundant  portion  of  the  lower  lip.  A  flap,  with  its  base  towards  the  posterior 
triangle  of  the  neck  on  the  left  side,  was  taken  from  the  area  as  shown  in  the  illustration, 
fig.  776,  and  was  swung  up  to  the  chin.  The  whole  of  the  pedicle  was  sewn  into  the  neck, 
and,  to  make  room  for  this,  some  of  the  scar  tissue  in  the  neck  was  cut  as  a  flap  and  transposed 
downwards  to  fill  up  the  raw  area.  The  post-operative  stage  was  interesting,  on  account 
of  the  effect  of  electro-therapeutic  measures  carried  out  soon  after  the  operation  ;  they 
were  mostly  in  the  form  of  the  vacuum  high-frequency  electrode.  At  the  end  of  the  third 
day  a  considerable  reaction  was  noticeable  in  the  way  of  increased  blood  supply  to  the 
flap.  This  may,  or  may  not,  have  had  a  detrimental  effect,  as  the  return  veins  and  efferent 
lymphatics  were  not  sufficiently  developed  to  carry  off  the  fluids  of  this  reaction,  and  stasis 
became  apparent  on  the  third  day.  To  aid  the  efferent  circulation  I  discontinued  the  electro- 
therapeutical  measures,  and  pricked  the  bluer  parts  with  a  fine,  sharp  needle.  Over  this 
pricked  area  Bier's  cupping  was  applied,  and  much  blood  and  lymph  were  extracted.  The 
colour  and  circulation  immediately  returned  right  to  the  extremity  of  the  flap,  but  twenty- 
four  hours  afterwards  the  blueness  had  returned  to  a  minor  degree  along  the  extremity  of 
the  flap  and  was  not  any  longer  amenable  to  treatment. 

The  amount  of  the  flap  lost  by  gangrene  is  well  shown  in  the  photograph,  fig.  776.  This 
loss  was  sufficient  to  cause  a  slight  pulling  down  of  the  lip  opposite  that  spot,  and,  to  cure 
this  and  raise  the  lip,  a  nasolabial  flap  was  later  swung  down  below  the  margin  of  the 
lower  lip.  At  the  same  time  the  thick  scar  band  from  the  right  aspect  of  the  mandible, 
extending  down  the  neck  to  the  clavicle,  was  treated  by  skin-graft  in  the  following  manner, 
which  is  similar  to  the  treatment  for  ectropic  conditions  of  the  eyelids.  An  incision  was 
made  right  across  the  scar  part,  which  was  dissected  out.  The  cavity  was  deepened  until 
the  neck  could  be  stretched  and  extended,  the  usual  mould  of  the  cavity  taken,  and  a  skin- 
graft  wrapped  around  it.  The  mould  on  this  occasion  was  made  of  paraffin  wax,  and  the 
skin-graft  was  a  Wolfe  graft. 

The  result  was  satisfactory  both  as  regards  appearance  and  function. 

7.12.17.  Operation. — Main  principle.—  Excision  of  scar  tissue  and  replacement  by 
a  long  broad  chest-flap,  having  its  base  of  attachment  in  the  left  posterior  triangle  of  the 
neck. 

Details. — The  scar  in  the  left  nasolabial  furrow  was  excised  and  the  skin  approxi- 
mated. Primary  union.  That  on  the  right  was  left  untouched.  The  excision  of  the  scar 
commenced  at  each  corner  of  the  mouth  and  was  carried  outwards  until  healthy  skin  was 
reached.  A  portion  of  the  everted  mucous  membrane  of  the  lower  lip  was  excised  with 
the  scar  tissue  about  \  in.  The  scar  tissue  varied  in  depth  ;  in  places  there  was  even 
healthy  skin  ;  in  others,  the  scar  tissue  extended  deep  into  the  muscular  layer  and  was 
quite  \  in.  in  thickness.  The  long  flap  was  outlined  as  in  the  diagram  and  swung  into 
position.  It  was  stitched  all  along  the  healthy  margin  of  the  skin  and  mucous  membrane. 
In  order  to  fit  it  in  better,  the  portion  of  the  front  aspect  of  the  neck  which  contained  a 
considerable  amount  of  scar  tissue  was  raised  and  swung  downwards  to  help  fill  up  the  gap 
on  the  chest. 


INJURIES    IN   THE   REGION    OF   THE   EYES 


379 


FIG.  775. — On  admission. 


Fio.  776. — Chest  flap  to  chin.     (See  text.) 


Progress. — The  blood  supply  of  the  flap  was  good,  but  considerable  swelling  occurred 
on  the  second  and  third  days  after  the  operation,  which  was  due  to  the  following  causes  : 

Lymphatic  and  venous  stasis  of  the  extremities  of  the  flap  occurred.  Blood  and  serum 
collected  under  the  flap,  which  was  therefore  drained  beneath  the  chin.  Portions  of  the 
flap — namely,  just  below  the  lip,  and  another  patch  on  the  right  and  another  smaller  patch 
on  the  left — became  blue  with  a  tendency  to  become  gangrenous.  The  vacuum  high- 
frequency  electrode  was  applied  to  the  flap  for  the  first  three  days  after  the  operation. 
On  the  third  day  pricking  of  the  blue  portions  of  the  flap  was  resorted  to  and  Bier's  cupping 
was  carried  out.  Large  quantities  of  lymph  and  blood  were  drained  away,  and  the  whole 
contour  of  the  flap  improved  considerably,  almost  to  the  normal.  Hot  fomentations  were 
applied  and  the  electrical  treatment  discontinued.  This  treatment  was  continued  for  the 
next  two  or  three  days,  but  gradually  a  line  of  demarcation  appeared  round  each  place, 
followed  by  suppuration  and  sloughing. 

17.6.17.  Condition. — There  was  some  ectropion  of  lower  lip,  right  corner,  due  to  the 
small  portion  of  the  chest-flap  which  sloughed  at  the  previous  operation.  In  addition, 
along  the  right-hand  edge  of  this  flap  was  a  thick  band  of  scar  tissue  which  prevented  the 
head  being  freely  extended. 

17.0.18.  Operation. — (1)  After  excision  of  scar  near  the  angle  of  the  mouth,  flap 
"  A  "  from  the  right  nasolabial  fold  was  brought  down  to  raise  the  corner  of  the  lip.  (2) 
To  divide  the  band  of  scar  tissue  satisfactorily  a  free  incision  was  made  across  it,  and  a 
cavity  made  into  which  a  mould  of  a  high-melting  paraffin  was  inserted.  A  whole-thickness 
graft  from  the  arm  was  wrapped  round  it  and  the  whole  buried.  There  resulted  complete 
relief  from  the  limitation  of  extension  of  the  head,  and  a  slight  improvement  in  the 
appearance. 


:38() 


PLASTIC    SURGERY 


Fio.  777.— Indicating  site  of  second  operations.     A  whole- 
thickness  graft  was  applied  after  excision  of  the  scar  "B." 


FIG.  778. — Note  scar  near  right  corner  of  mouth. 


Fia.  779.— Final  :   After  excision  of  scar  and  descending  nasolabial  flap. 


INJURIES    TO    THE    PINNA 

DEFECTS  and  burns  of  the  pinna  form  a  small  proportion  of  facial  injuries. 
The  gunshot  injuries  met  with  may  be  thus  classified  :  Scars,  perforations, 
marginal  losses,  losses  of  the  lobule,  and  large  and  total  losses  of  the  pinna. 

Scars  do  not  always  need  treatment  :  owing  to  the  breadth  of  the  patient's 
head  relative  to  the  width  apart  of  the  observer's  eyes  and  the  distance  at  which 
ordinary  conversation  is  conducted,  it  happens  that  both  ears  are  seldom  seen 
in  the  same  glance.  Consequently,  minor  degrees  of  asymmetry  are  negligible. 

Perforations  of  the  concha  readily  lend  themselves  to  repair  by  means  of 
a  flap  swung  from  the  back  of  the  pinna,  as  indicated  in  figs.  780-783. 


Fio.  780.— Perfora- 
tion :  Ascending 
flap  outlined. 


Fio.  781.— Flap 
being  swung 
up. 


Fio.  782.— Per- 
foration 
closed. 


Fio.  783  .— 
Raw  area 
grafted. 


Marginal  losses  present  more  difficulty  :  the  contour  of  the  helix  must 
be  restored.  In  small  losses  the  author  has  successfully  applied  the  principle 
of  turning  up  a  flap  from  the  back  of  the  pinna  containing  a  previously  buried 
piece  of  cartilage,  after  the  method  outlined  in  figures  784-787.  Case 
No.  622  was  treated  in  this  manner.  (See  photographs,  figs.  788  and  789.) 

If  merely  a  small  piece  is  required,  the  cartilage  is  taken  from  the  same 
or  the  other  concha,  where  experience  shows  that  the  removal  is  not  followed 
by  disfigurement.  Otherwise,  it  is  taken  from  the  rib  and  suitably  shaped. 


381 


PLASTIC    SURGERY 


CASE  622 

Operation  notes : 

•1.12.18. — Piece  of  cartilage  from  anti-hdix  of  left  car  was  removed  subcutaneously — 
of  the  necessary  length  and  curve — to  complete  the  gap  in  the  pinna.  (This  through  an 
incision  along  the  border  of  the  anterior  surface.)  The  cartilage  was  now  imbedded  into 
a  flap  on  the  posterior  aspect  of  the  pinna,  which  is  to  be  swung  upwards  as  a  skin-cartilage 
flap  later. 

3.3.19.— Replacement  of  missing  portion  of  helix  of  left  ear  by  flap  from  post- 
auricular  region. 

21.5.19. — Piece  of  cartilage  from  right  anti-helix  dissected  and  implanted  to  form 
free  border  of  new  portion  of  left  ear. 

1.6.19.  — The  top  edge  i s  curved  back  a  little.     Patient  not  desirous  of  further  treatment. 


FlO.  784.— Showing 
defect ;  Cartilage 
implanted  and 
flap  outlined. 


FIG.  785.— Flap 
being  swung 
up. 


FIG.  786.— Flap 
in  position. 


FIG.  787.— Raw 
area  grafted. 
(In  Case  622  a 
flap  was  used.) 


Fio  7S8.— Showing  marginal  defect. 


Fio.  789.— Present  condition.     Requires  trimming 
up  to  complete. 


INJURIES    TO    THE    PINNA 


.'38.'} 


Larger  marginal  losses  are  amenable  to  a  type  of  repair  comparable  with 
this,  but  on  a  larger  scale. 

Here,  as  in  the  cases  of  total  loss,  the  principle  employed  is  the  preliminary 
reconstruction  of  the  missing  organ  by  imbedding  cartilage  under  the  skin 
bordering  on  the  defect,  followed  by  the  elevation  of  the  new  pinna  into  position 
as  a  second  step. 

In  Case  No.  3,357,  a  subtotal  loss  (see  figs.  795  and  796),  the  support  of  the 
new  pinna  was  accurately  fashioned  in  cartilage  taken  from  the  seventh  and 
eighth  ribs. 

This  was  inserted  beneath  the  hair-free  skin  over  the  mastoid  process  and 
the  skin  pressed  down  into  its  irregularities  by  means  of  Stent.  Unfortunately, 
the  pressure  thus  applied  proved  too  much  for  the  blood  supply,  and  much  of 
the  cartilage  forming  the  helix  and  anti-helix  sloughed.  The  result  of  this 
stage  is  shown  in  fig.  797. 

Four  months  later  a  flap  containing  this  cartilage  was  swung  outward 
and  forward  on  a  pedicle  consisting  of  the  stump  of  the  original  pinna. 

The  resulting  raw  area  on  the  back  of  the  new  pinna  and  over  the  mastoid 
process  was  covered  by  a  flap  taken  from  the  posterior  triangle  of  the  neck. 
The  man's  present  condition  is  seen  in  fig.  798.  The  diagrams  .of  these  stages 
are  indicated  in  figs.  790-794. 

Operation  notes  of  this  case  are  as  follows  : 


13.2.19. — Otoplasty.     Implantation  of  cartilage  to  left  ear. 
6.6.19.— Plastic  to  left  ear. 

6.8.19. — Blood  examined.     Pathologist'*-   report:   strong  positive, 
some  bearing  on  the  fate  of  the  graft.) 


(This   may  have 


FIQ.  790. —  Rib  -  cartilage 
shaped  to  represent  miss- 
ing portion. 


FIG.  791  .—Shaped  car 
tilage  graft  inserted 
subcutaneously. 


FIG.  792. — Skin  sutured  over  the  graft. 
Stent  was  applied  to  press  the  skin 
accurately  into  the  hollows. 


384 


PLASTIC    SURGERY 

()/  CASE    3357 


Fio.  793. — Operation  four  months  after  cartilage  im- 
plant. Skin-cartilage  flap  swung  forward.  Raw 
area  to  be  covered  by  flap  from  posterior  triangle. 


Fio.  795. — Showing  subtotal  loss  of  pinna. 


FIG.    794. — Suture.     The    raw    area  on  the  neck 
was  easily  covered  by  advancement  of  the  edges 


FIG.  796. — Lateral  view. 


FIG.  797. —  After  cartilage  implant.       (Much  of  it 
sloughed.   ?  due  to  blood  condition.  See  notes.) 


FIG.  798. — Present  condition. 


INJURIES    TO    THE    PINNA 


385 


Loss  of  the  lobule  has  been  made  good  by  means  of  a  post-auricular  flap  which  is  made 
to  form  the  anterior  surface  of  the  lobule,  the  posterior  covering  being  supplied  by  skin- 
grafting  the  raw  area. 

Case  No.  2251  was  treated  in  this  way,  and  the  stages  in  the  sufficiently 
good  result  obtained  are  seen  in  figs.  803-805. 

The  operation  notes  for  this  case  are  as  follows  : 

6.2.19. — Post-auricular  flap  incised  and  turned  up,  having  as  its  pedicle  the  remaining 
portion  of  the  ear.  An  incision  was  then  made  about  4  in.  long  at  lower  adherent 
portion  of  ear,  and  part  of  the  flap  was  sutured  to  this  incision.  The  raw  portion  of  the 
flap  and  the  bed  of  the  flap  were  covered  by  a  Thiersch  graft  under  stent. 

14.5.19. — The  lobular  portion  of  the  left  ear  was  advanced  about  J  in.  by  a  vertical 
incision. 

Diagrams  illustrative  of  the  method  employed  in  this  case  are  given,  and 
diagrams  for  an  alternative  method  are  also  shown. 


FIG.  799. — Showing  defect, 
and  outlining  of  flap. 


FIG.  800.— Flap  being 
swung  forward. 


FIG.  801.— Suture. 


FIG.  802.— Graft  to 
raw  area. 


It  will  be  realised  that  the  diagrams  throughout  this  section  are  what 
might  be  termed  "  ultra-diagrammatic."  They  were  prepared  from  a  verbal 
description,  as  it  was  found  that  photos  of  some  of  the  stages  failed  to  give 
any  idea  of  the  procedure  adopted. 

25 


38(5 


PLASTIC    SURGERY 


CASE  2251 


Fio.  803. — Showing  the  defect. 


Fia.  804. — Soon  after  plastic. 
Side  view. 


Fia.  805. — Soon  after  plastic.     Posterior  view.      The  Thiersch  graft  failed  to  take  in  parts. 


Fio.  800.— Showing  defect, 
and  proposed  flap  outlined. 


Kid.  81)7. — Flap  swung  down  FIG.  808.— Suture.  Fio.  809. — Raw  area 

and  being  doubled  upon  itself.  grafted. 

SUGOESTKD  ALTERNATIVE  METHOD  OF  MAKING  THE  LOBULE. 


INJURIES    TO    THE    PINNA  387 

Burns  are  often  followed  by  adhesions  of  the  remnants  of  the  pinna  to  the 
skin  over  the  mastoid  process.  Here  the  epithelial  inlay  is  indicated,  and  in 
cases  with  small  loss  of  substance  the  freeing  of  the  pinna  produces  a  sufficiently 
satisfactory  result. 

CASE  3359 


FIG.  810. — Shows  result  of  epithelial  outlay  used  as  a  means  of  freeing  the  upper  portion  of  the 
pinna  which  was  adherent  to  the  scalp.  (Photo  of  pre-operative  condition  not  available.) 
The  limits  of  the  outlay  can  be  seen  with  difficulty. 

Operation  notes : 

20.9.18. — Right  pinna  dissected  from  scalp  to  which  its  upper  portion  was  adherent. 
Mould  of  raw  cavity  thus  formed  taken  with  warm  stent.  Thiersch  wrapped  round  stent, 
raw  area  outwards,  and  placed  in  the  cavity.  Free  edge  of  pinna  sewn  back  to  original 
position  against  scalp. 

30.9.18. — Stitches  cut,  stent  removed.     Graft  taken  nicely. 

In  these  burnt  cases  there  is  usually  so  much  concomitant  scarring  that 
local  flaps  are  not  available,  and  the  question  of  the  expediency  of  restoring 
the  pinna  by  neck  or  chest  flaps  is  intimately  associated  with  the  problem 
of  the  whole  facial  restoration.  It  is  found,  as  a  matter  of  practice,  that  the 
ear  defect  in  a  severe  burn  is  a  minor  part  of  the  disfigurement,  and  does  not 
usually  justify  the  time  and  trouble  that  its  cure  requires. 


PLASTIC  8URGEEY  IN   CIVIL    CASES 


389 


CHAPTER   VIII 
PLASTIC  SURGERY  IN  CIVIL   CASES 

THE  application  of  the  methods  described  and  discussed  in  the  previous  pages 
will,  in  the  author's  opinion,  have  considerable  effect  upon  the  possibilities  of 
plastic  surgery  amongst  the  civil  community.  It  may  be  also,  that,  apart  from 
the  much  wider  field  of  deformities  which  will  be  brought  into  the  class  in  which 
successful  restoration  can  be  applied,  the  treatment  of  the  disease  itself,  in 
addition  to  the  deformity  caused  by  the  disease  or  injury,  will  be  modified. 
Thus,  when  it  is  demonstrated  that  successful  and  cosmetic  rhinoplasty  is  an 
operation  that  can  be  counted  on  with  reasonable  certainty,  the  early  treatment 
of  lupus  may  be  modified  in  the  direction  of  complete  excision  of  the  affected 
area  regardless  of  the  deformity  so  caused. 

Should  this  suggested  line  of  treatment  be  practical  in  removing  the  disease, 
years  of  local  therapy  will  be  dispensed  with. 

Many  of  the  cases  that  the  author  has  treated  for  healed  lupus  deformities 
had  a  history  lasting  for  ten  or  fifteen  years,  and  presented  tissues  so  scarred 
and  fibrosed  that  the  work  of  the  plastic  surgeon  was  greatly  hampered.  Had 
it  been  possible,  in  such  cases,  to  have  excised  the  tip  of  the  nose  with  the 
adjacent  lymphatic  tracts  in  the  naso-labial  folds  completely  in  the  early  stages, 
successful  nasal  reconstruction,  with  far  less  resultant  deformity,  could  be  reason- 
ably guaranteed,  and  the  treatment  markedly  shortened. 

Taking  the  situation  as  it  is  at  present,  there  are  many  thousands^of  cases 
in  the  world  of  healed  lupus  whose  scarred  facial  remains  are  so  distorted  that 
most  of  them  have  to  live  a  secluded  or  semi-secluded  life. 

Even  in  this  scarred  class  of  case  gratifying  results  of  rhinoplasty  have 
already  been  obtained  by  the  author. 

It  is  found  advisable  to  modify  somewhat  the  plan  of  treatment  in  these 
cases,  particularly  in  regard  to  two  points. 

One  of  these  points  is  that  the  inturned  flaps  to  form  the  skin  lining  of  the 
new  nose  have  to  be  so  designed  that  they  have  a  larger  blood  supply  than  is 
usually  deemed  sufficient  in  the  non-lupus  cases. 

The  second  point  is  that  the  tissues  are  more  liable  to  suppurative  troubles, 
and  it  is  unwise  to  take  the  risk  of  immediate  cartilage  implantation  between  two 
epithelial  flaps. 

Examples  of  this  are  given  among  the  cases  which  follow. 

391 


392  PLASTIC    SURGERY 

Turning  to  syphilis,  as  the  principal  peace-time  destroyer  of  the  nose,  the 
author  has  not  yet  seen  a  case  which  is  not  amenable  to  the  methods  evolved 
by  him  during  the  war. 

These  cases  appear  to  be  quite  comparable  with  the  war  injuries,  provided 
that  diagnosis  is  made  of  the  tissue  lost,  and  repair  is  designed  to  make  good 
such  losses ;  and  the  results  are  very  encouraging. 

In  one  of  the  cases  illustrated  the  main  loss  of  tissue  was  in  the  mucous 
membrane  lining.  There  was  also  concomitant  loss  of  the  cartilage  supports, 
while  the  skin  covering  was  almost  intact. 

The  provision  of  a  skin-graft  for  the  lining  and  cartilage  for  the  support 
was  sufficient  to  produce  a  good  result. 

In  a  second  case  of  hereditary  syphilis  total  loss  of  the  nose  existed.  All 
structures,  including  the  bony  supports,  lateral  and  central,  had  been  destroyed 
by  the  disease.  The  early  result  of  rhinoplasty  in  this  case  is  illustrated. 

Depressed  fractures  of  the  nose,  either  with  or  without  lateral  deviation,  are 
best  treated  by  cartilage  implantation.  In  some  cases,  however,  especially 
where  there  is  lateral  deviation  only,  it  is  possible  to  refracture  the  nose  and 
set  it  straight.  Naturally  the  surgeon  will  pay  attention  to  the  freeing  of  the 
airway  in  all  cases. 

In  regard  to  hare-lips,  the  author  does  not  intend  to  discuss  the  early 
operative  treatment  which  is  so  fully  known  and  appreciated  by  the  surgical  pro- 
fession. It  has,  however,  occurred  in  the  author's  practice  to  treat  a  number 
of  cases  the  results  of  whose  early  operations,  good  though  they  are,  were 
capable  of  being  treated  on  lines  similar  to  those  suggested  in  this  book. 
Corrections  of  the  line  and  the  contour  of  the  new  lip,  and  the  position  of 
the  columella  and  alse  can  quite  often  be  effected,  while  interpolation  of  an 
epithelial  inlay  will  often  produce  a  contour  which  effects  an  astonishing  improve- 
ment. 

Burns  of  the  face  are  a  common  injury  in  civil  as  in  military  practice, 
and  do  not  require  special  treatment  in  this  chapter. 

The  author's  operation  for  epithelial  outlay  has  already  produced  a  great 
relief  to  patients  afflicted  with  cicatricial  ectropion.  The  possibility  of  removal 
of  nsevoid  disfigurements  springs  to  one's  mind,  and  many  such  are  amenable  to 
the  newer  methods. 

Rhinophyma  obviously  lends  itself  to  most  gratifying  rhinoplasty,  either  by 
forehead  flap  or  Wolfe  graft. 

Over-developed  and  under-developed  noses  can  be  corrected  without  scarring 
or  any  secondary  disfigurement. 

A  few  examples  of  completed  and  semi-completed  cases  of  facial  dis- 
figurement are  appended. 


PLASTIC   SURGERY  IN   CIVIL   CASES  393 

The  principles  the  development  of  which  has  been  indicated  by  this  book 
are,  naturally  enough,  not  applicable  merely  to  facial  surgery.  The  principle 
of  tubing  the  pedicle  of  a  flap  has,  at  one  bound,  pointed  the  way  to  dealing 
with  a  reasonable  loss  of  skin,  traumatic  or  pathological,  from  any  part  of  the 
body  surface.  Skin  may  be  brought  by  this  means  from  any  part  to  any  other 
—in  one  step  for  distances  not  exceeding  ten  inches — otherwise  in  several 
steps,  the  source  and  direction  of  the  blood  supply  being  changed  each  time 
the  existing  base  becomes  the  free  end. 

It  should  even  be  possible  to  establish  a  satisfactory  ambulatory  treat- 
ment for  varicose  ulcers. 

The  surgeon  may  now  deal  fearlessly  with  almost  any  ulcer  that  can  be 
excised  or  rendered  clean,  secure  in  the  knowledge  that  a  covering  of  healthy 
skin  can  be  provided  for  the  raw  area  resulting  from  his  interference.  Further, 
it  is  not  too  much  to  say  that  contractures  should  not  now  be  allowed  to  occur 
after  burns.  The  impending  deformity  can  be  anticipated  by  a  thorough 
excision  of  scar  tissue  followed  by  the  use  of  skin -flaps,  tubed,  say,  three  weeks 
before,  from  the  periphery  of  the  defect.  Webbed  fingers  and  other  similar 
deformities  should  present  problems  now  greatly  simplified. 

The  tubed  flap  may  be  made  to  bear  within  its  substance  or  upon  its  sur- 
face supplies  of  skin,  hair,  mucosa,  fat,  connective  tissue,  bone,  cartilage  or 
blood-vessels — in  fact  any  of  the  less  highly  organised  tissues.  There  is  scope 
for  the  transplantation  of  such  material  in  the  restoration,  not  only  of  surface, 
but  of  tissues  bordering  thereon.  The  gap  left  by  the  removal  of  the  female 
breast  should  be  remediable  in  terms  of  tubed  flaps  designed  to  carry  large 
masses  of  fat,  e.g.  from  the  buttock,  along  the  lines  indicated  in  figs.  811  to  816. 

The  principle  of  replacement  in  kind  for  lining  membranes  as  for  coverings 
finds  a  field  wherever  trauma  or  disease  have  transgressed  the  barriers  that 
separate  these  two  types  of  tissue.  Thus  a  severe  degree  of  stricture  of  the 
urethra  should  lend  itself  to  excision  followed  by  the  reconstitution  of  the 
mucosal  lumen  by  a  Thiersch  graft  applied  by  some  modification  of  the  Esser 
Inlay. 

In  this  connection,  pre-natal  disease  offers  a  vast  field.  Conditions  such 
as  Ectopia  Vesicte,  Hypospadias,  Meningoccele,  Imperforate  Anus,  and  various 
forms  of  fistulse  offer  scope  for  the  application  of  these  principles  in  combination. 


394 


PLASTIC    SURGERY 


Flo.  811. — Breast  excised  ;   flap  outlined. 


Fio.  812.— The  pediole  "tubed." 


tt<  -The  fat-carrying  flap  being  swung  up  to  the  defect,. 

MKTHOD  OF  HESTORING  THE  CONTOUH  OF  THE  BREAST  AFTER  EXCISION. 


PLASTIC   SURGERY   IN   CIVIL   CASES 


395 


FIG.  814.— The  flap  sutured  into  place. 


FIG.  815. — The  pedicle  severed,  opened  out,  and  being 
swung  up  to  reinforce  the  flap. 


FIGS.  81 1  and  812  represent  the  first  stage, 
which  would  be  followed  by  an  interval 
of  at  least  ten  days. 

FIGS.  813  and  814  represent  the  second 
stage,  also  followed  by  a  ten-day 
interval. 

FIGS.  8 1 5  and  8 1 6  represent  the  final  stages. 


FIG.  810.  — Suture. 


J39G 


PLASTIC    SURGERY 


FIGS.  817  and  818. — Hereditary  specific  disease :  total  destruction  of  nose.  In  these  photographs  a  piece  of 
cartilage  has  been  imbedded  above  the  nasal  aperture,  and  a  thin  piece  laterally  in  each  naso-labial  fold  to  form 
the  bridge  and  ala  supports  respectively. 


Flos.  819  and  820. — Early  result  :   Rhinoplasty  from  the  forehead  by  tubed  pedicle  method. 


Fio.  821. — Dog  bite  of  lip. 


Fid    822. — Result  of  sewing  small  flap  into  lip 
to  replace  scar. 


PLASTIC    SURGERY    IN    CIVIL    CASES 


397 


Fios.  823  and  824. — Acquired  destruction  of  nose.     (Paraffin  had  been  injected  to  raise  the  bridge.) 


FIG.  826. 


FIG.  825.  FIG.  827. 

FIG.  825.  Intermediate. — Intermediate  stage,  showing  result  of  skin-graft  to  inside  of  nose.  The  skin-graft  was 
inserted  from  an  incision  beneath  the  lip,  held  in  position  by  stent  mould,  which,  in  itself,  was  held  in  position  by 
a  dental  splint  passing  through  an  existing  palatal  perforation.  The  nose  is  here  seen  supported  by  a  dental 
appliance  taking  its  purchase  from  the  upper  teeth,  and  supporting  the  bridge  through  the  palate.  This 
appliance  was  made  and  designed  by  Major  Kenneth  Russell,  A.A.D.C. 

FIGS.  820  and  827. — Finals:  Result  after  cartilage  implantation.  Cartilage  taken  from  another  case  and  inserted 
through  the  tip.  The  appliance  to  the  nose  is  worn  no  longer,  as  the  cartilage  is  sufficient. 


898 


PLASTIC    SURGERY 


Fios.  828  and  829. — Traumatic  loss  of  the  tip,  eolumella,  and  also  of  the  nose.     Much  forehead  scarring, 
and  part  loss  of  upper  lip.     (There  had  been  previous  attempts  at  restoration.) 


FIGS.  830  and  831.— Finals  :  Result  of  rhinoplasty. 


I  n..   s:t:!.      Kxrussive  prominence  of  nasal   bridge. 


Flo.   833. — After  operation   by  excision. 


PLASTIC    SURGERY    IN    CIVIL    CASES 


399 


FIGS.  834  and  835. — Traumatic  deformity  of  nose. 


FIGS.  830  and  837. — Result  of  cartilage  implantation. 


FIG.  838. — Arrested  development  of  nose 
from  natal  injury. 


FIG.    839. — Result  after  cartilage 
implantation. 


400 


PLASTIC    SURGERY 


FIGS.  840  and  841. — Deformity  of  nose  following  lup 


Fio.  842. — Rhinoplasty  by  temporal  artery 
tube  pedicle  flap. 


FIQS.  843  and  844. — Result  of  rhinoplasty. 


INDEX 


Acid  burns,  347 
Advancing  flaps,  19,  20 

in  rhinoplasty,  214,  248 

in  upper  lip  injuries,  101 
After  treatment,  34 
Airman's  burns,  347,  372-375 
Air-way,  nasal,  bleeding  into,  27,  28 

clearing  of,  213 

establishment  of,  271,  278 

Hewitt's,  27,  28 

obstructed,  ansesthesia  with,  27 
due  to  loss  of  columella,  202 
Ala,  injury  to,  author's  method  of  treatment,  258 
Wolfe  graft  in,  247 

loss  of,  246,  398 

cases  illustrating,  247-257 

new,  provision  of,  252,  255,  263 

operation  on,  225 

partial  loss  of,  267,  269 

pug-nose  deformity  of,  230,  231 
cases  illustrating,  232,  237-239 

skin  lining  for,  212 
Alveolar  process,  loss  of,  64 
Alveolus,  palatal  injuries  involving,  207 
Anaesthesia,  23 

chloroform  and  oxygen,  in  sitting-up  position, 
24 

coughing  during,  26 

for  rhinoplasty,  27 

intra-tracheal,  23 

nasal  tube  for,  25 

oil-ether,  27,  28 

paraldehyde,  28 

position  during,  24 
Anus,  imperforate,  393 
Appliances.     See  Prosthetic  appliances 
Approximating  hooks,  50 
Ascending  flaps,  19 

for  upper  lip  injuries,  77,  78,  80 

in  ear  injuries,  381 

in  eye  injuries,  314 
Asepsis,  during  suture,  33 
Autologous  cartilage  graft  to  nasal  bridge,  293 
Autologous  osteochrondral  mandible  graft,  179, 
180,  181 

Ball  cartilage  eyes,  336,  339 
Bird-beak  type  of  nose,  217 
Blepharoplasty,  inferior,  313 

flaps  in,  314 
principles  of,  313 
superior,  329 
cases  illustrating,  330-331 


Blepharoplasty,  principles  of,  329 

suture  in,  315 

Blood  supply  of  Haps,  30,  77-79 
Bone  grafts,  183-189 

anaesthesia  during,  28 

restricted  use  of,  12 

to  the  mandible,  methods,  177-180 
Bony  chin,  loss  of,  123 
Bony  loss,  estimation  of,  5 

extensive,  198 

in  cheek  and  jaw  injuries,  52,  64 
cases  illustrating,  52-63,  64-74 

in  eye  injuries,  301,  304,  306,  308 

prosthetic  replacement  of,  200 
Bridge  pedicle  Haps  in  upper  lip  injuries,  98,  115. 

See  also  Pedicle 
Buccal  fistula,  50,  70 
Buccal  orifice,  widening  of,  132 
Buccal  restoration,  8,  9 
Burns,  cases  illustrating,  353-380 

after  treatment  of,  351 

causes  and  varieties  of,  347 

facial,  18,  347,  349 

causing  microstoma,  123 

of  the  ears,  347,  381 

of  the  eyelids,  347,  349 

treatment  of,  348,  349 
errors  in,  351 


Canthoplasty,  324,  325 

method  of  obtaining,  13 
Cartilage  flaps,  in  eye  injuries,  315 

in  nose  injuries,  217,  230,  231,  234,  258 

in  pinna  injuries,  382,  384 
Cartilage  grafts,  12,  13 

homologous  and  autologous,  13,  14,  15 

in  cheek  injuries,  45 

in  eye  injuries,  303,  307,  309,  338,  344 

in  operation  for  orbicularis  palsy,  344 

in  pinna  injuries,  383 

Cartilage    implants,    for   depressed    fractures    of 
the  nose,  392 

in  extensive  cheek  injuries,  73,  74 

in  eye  injuries,  336 

in  inferior  blepharoplasty,  314,  315 

in  pinna  injuries,  383-384 

in  nose  injuries,  212,  219,  223,  227,  264,  266, 
268,  399 

to  malar  region,  309 

Cartilaginous  supports,  skin-flaps  used  in  associa- 
tion with,  22 
Caterpillar  movement,  in  nose  repair,  250,  251 


20 


401 


INDEX 


Catgut  sutures,  32 

Olluloul  plate,  for  facial  contour,  12 

in  cheek  repair,  52,  53.  .">  I 
Celluloid  supports,  Indian  rhinoplasty  over 
Check,  adherent  to  palate,  207 

excision  and  incision  of  scars  of,  61,  *>6,  «>J.  ° 
loss  of  bony  framework  of,  52 
mucous  flap  from  inside  of,  139 
reconstruction  after  nasal  operation,  212 
repair  of  the,  37 

Cheek-Haps,  in  lip  injuries,  87,  129,  1»» 
in  injuries  to  palate,  207 
in  rhinoplasty,  3 
Cheek  injuries,  37-38 

celluloid  implantations  in,  53,  54 
complete  loss  in,  71,  72 
depressed  scars,  37,  38 

cases  illustrating,  39-41 
extensive  destruction  in,  72 
extensive  loss  of  soft  parts,  appliance  used  in, 

195 

fat-grafts  in,  44 

hollow  filled  by  fat-graft  in,  115 
horsehair  mattress  sutures  in,  57 
loss  of  soft  tissue  only,  42 
cases  illustrating,  42-51 
restoration  from  post-aural  region,  374 
sutures  in,  63,  65 
teeth  carried  through,  50 
total  loss  of  nose  with,  294 
triangular  opening  in,  60     j 
with  loss  of  bone,  52,  62 

cases  illustrating,  52-63 
with  superior  maxillary  loss,  64 

cases  illustrating,  64-74 

Chest,  tube  pedicle  rhinoplasty  from,  212,  213 
Chest-Haps,  for  facial  losses,  14,  352 
in  rhinoplasty,  212,  213 
to  chin,  370,  379 

Chin,  anesthesia  during  operations  on,  26 
new,  operation  for  provision  of,  175 
prosthetic  replacement  of,  174 
viability  of  llaps  near,  22 
Chin-flaps,  for  upper  lip  injuries,  78,  80,  90 
Chin  injuries,  123,  124,  158 

cases  illustrating,  125-189 
chest  llaps  in,  370,  379 
descending  nasolabial  cutaneo-muscular  flap  in, 

160 

excision  of  scar  tissue  in,  165 
extensive  loss  in,  162,  168,  172 
forehead  flap  in,  176 
neck-Hap  in,  159 
scalp-Hap  in,  170 
scar  excision  in,  164,  167 
soft  tissues,  165,  166,  172 
suture  in,  157,  163,  164,  167 
Chloroform  and  oxygen  anaesthesia,  methods,  24- 

26 

technique,  '2  I 
Civil  rases,  plastic  surgery  in,  391 

illustrations  of.  :t'.»l    100 

Cleft  palate,  aiia-slhesia  during  operations  on,  25 
Colmnella.  and  upper  lip  repair,  82 
artificial,  203.  27.'),  2*7 
celluloid  support  to,  22li 
deficiency  of,  253 


Columclla.  detachment  of,  252 

loss  of,  398 

obstructed  airway  due  to  loss  of,  202 

operation  on,  95 
Concha,  perforation  of,  381 
Conjunctiva,  deficiency  of,  332 

incision  through,  332,  333 
Contour.     See  Facial  contour 
Cordite  burns,  347 

Coughing,  prevention  during  anaesthesia,  ^o 
Covering  tissues,  16 

Cranial  defects,  loss  of  bone  constituting,  301 
Cyanosis  during  anaesthesia,  24,  25 

Deformity,  scar  tissue  in  relation  to,  30 
Deglutition,  impaired,  124 
Dental  appliances  in  palatal  injuries,  205, 
Dental  fixation,  nasal  splint  with,  201 
Dental  splints,  194 

in  mandible  injuries,  177,  195 
use  of,  194-196 
use  in  epithelial  inlay,  10 
Dental  sulcus,  reformation  of,  197 

prevention    of    encroachment    of    soft    tissue 

upon,  196 

preservation  of,  194,  195 
Dental  surgeon,  role  of,  6,  7, 10,  193,  206 
Dentures,  193 
functional,  200 

in  upper  lip  injuries,  82,  83,  92,  93 
prosthetic  support  of,  200 
with  artificial  pre-maxilla,  92 
Depressed  scars  of  the  cheek,  37-38 
Depressor  musculature,  for  the  jaw,  123,  124 
Descending  flaps  in  eye  injuries,  314 
in  lower  lip  injuries,  142,  148,  150,  154 
in  upper  lip  injuries,  78,  97,  103 
Descending  naso-iabial  flaps,  19 
Diagnosis,  data  for,  5 

depending  on   accurate   estimation   of   tissues 

lost,  146 
mistakes  in,  4 

Digastric,  epithelialisation  of,  124 
Dressings,  33 


Ears,  burns  of,  347,  381 

flaps  from,  in  blepharoplasty,  313 

injuries  to,  381 
flaps  in,  381 

restoration  of  lobule  of,  386 

See  also  Pinna  injuries 
Ectopia  vesicse,  393 
Ectropic  conditions,  epithelial  outlay  an,  K 

modification  of  epithelial  inlay  in  cure  of,  9 
Ectropion,  354,  355,  358,  361,  362,  363 

cicatricial,  following  burns,  349,  354 
treatment  of,  349 

of  lower  lip,  125 

of  upper  lip,  115 

traumatic,  313 

Wolfe  graft  relieving,  366 
Electrical  post-operative  treatment,  34 
Electric  burns,  348 
Entropion,  332 

Epicanthus  following  burns,  351 
Epilation,  9 


INDEX 


403 


Epiphora,  due  to  orbicularis  palsv,  344 
Epithelial  inlay,  9-12 

advantages  of,  200 

anaesthesia  during,  25 

for  stenosis  of  anterior  nares,  213 

in  eye  injuries,  325,  332 

in  mouth  injuries,  200 

new  nasal  tip  and  alse  by,  263 

splint  with  ilange  to  maintain  stent  for,  197 
Epithelial  lining,  in  nose  injuries,  221 

provision  of,  8 
Epithelial  outlay,  16 

in  ectropic  conditions,  16 

in  eye  injuries,  stages  of,  350,  363 

in  eyelid  injuries,  289,  330,  331,  349,  358,  376 

in  pinna  injuries,  387 

stages  in,  17 

Esser  inlay.     See  Epithelial  inlay 
Ether  anaesthesia,  27 
Ether  swab,  preparation  of  skin  for  operation  by, 

29 

Examination  of  cases,  principles  of,  4 
Excision  of  facial  wounds,  6 
Extra-oral  appliances  in  nose  injuries,  201,  202, 

203 
Eye  injuries,  203 

bony  loss  in,  304,  306,  308 

cartilage  grafts  in.  303,  307,  309,  338 

cranial  loss  in,  306 

epithelial  inlay  in,  325,  332 

epithelial  outlay  in,  349 
stages  in,  350,  363 

failures  in  operations  in,  causes  of,  322 

flaps  in,  304,  318,  328,  358 

infra-orbital  depression,  311 

pedicle  flaps  in,  309,  358,  362,  365,  369 

prosthetic  appliances  in,  203-205,  335 

orbital  ring,  301 

scar  excision  in,  202 

suture  in,  302,  308,  323 

temporal  flap  in,  308 

Tripier  operation  in,  59 

See  also  Blepharoplasty 
Eyebrow,  artificial,  301 

loss  of,  301,  304 

replacement  of,  18,  301 
Eyes,  artificial,  336,  337 

insertion  of,  204,  340,  342 
cases  illustrating,  338-343 

burns  of,  347-349 

flaps  near,  19 

paralysis  of  muscles  of,  344 

primary  enucleation  of,  336 
Eyelashes,  tattooing  for,  329 
Eyelids,  artificial,  construction  of,  204 

bums  of,  347,  349 

after  treatment  of,  351 
cases  illustrating,  353-380 
errors  in  treatment  of,  351 
treatment  of,  348,  349 

destruction  of,  313 

distorted,  replacement  of,  316 

ectropion  of,  epithelial  outlay  in  operation  for, 
16,  17 

epithelial  outlay  to,  289,  358,  376 

incision  in,  317 

injuries  to,  313 


Eyelids,  injuries  to,  cases  illustrating,  316-331 
lower,  lack  of  muscle  power  in,  57 
lymph-oedema  of,  326,  328 
operations  on,  313 
rebuilding  of  ocular  aspect  of,  8 
reproduction  of  action  of,  344 
tattooing  of,  329 
upper,  drooping  of,  204 

flap  from,  314 

loss  of,  329,  330,  331 

lymph-oedema  of,  58 

reconstruction  of,  329 
Eyesockets,  contracted,  332 

following  defective  rhinoplasty,  8 
epithelialisation  of,  203,  343 

appliance  for,  204 
injuries  of,  332 

cases  illustrating,  334 
inlay,  325 
replacement  of,  74 
sunken,  336,  341 

cases  illustrating,  338-343 
Tripier  operation  on,  58,  59 

Face,  burns  of,  18,  347,  349 
cases  illustrating,  353-380 
errors  in  treatment  of,  351 
treatment  of,  348,  349 

deformity  of  upper  part  of,  194 

destruction  of  greater  portion  of,  72 

scars  of,  plastic  treatment  of,  391 
Facial  contour,  building  up  of,  12-14,  193-195 
skin-grafts  in,  16 

fat  and  muscle  flaps  for,  14,  30 

loss  of,  extraordinary  example  of,  71,  72 

observations  on,  12 

scar  tissue  and,  30 
Facial  scars,  invisible,  33 

Facial  wounds,  avoidance  of  secondary  haemor- 
rhage in,  7 

cartilage  grafts  in,  14 

early  treatment  of,  5- 

excision  of,  6 

plan  of  restoration  in,  8 

planning  the  late  repair  of,  7 

supporting  structure  for,  12 

suture  for  closure  of,  32 
Failures  in  plastic  surgery,  to  what  due,  4 
Fat-flaps,  30 

in  restoration  of  contour,  14,  30 
Fat-graft,  hollow  in  cheek  filled  by,  115 

to  cheek,  44 

use  of,  14,  16 

Fat  implants,  in  eye  injuries,  336 
Fatigue,  prevention  of,  during  operation,  29 
Fistula,  buccal,  50,  70 
Flame-thrower,  burns  from,  348 
Flanges  for  splints  and  dentures,  194,  196,  197 
Flaps,  about  the  eyes,  19 

advancing,  19 

ascending,  for  lip  injuries,  77-78 

blood  supply  of,  30,  77-79 

cartilage  supports  and,  22 

descending,  for  upper  lip  injuries,  78 

descending  naso-labial,  19 

early  cutting  of,  not  recommended,  6 

for  facial  burns,  352  , 


404 


INDEX 


Hups.  forehead,  18,  176,  282 

grafts  sometimes  more  suitable  than,  22 

hair-l)caring,  9,  77 

in  chin  injuries,  158,  160,  163,  170,  173,  176 

indications  for,  16 

in  car  injuries,  381 

in  eye  injuries,  304,  313,  314,  318,  324,  358, 
365 

in  inferior  blepharoplasty,  313,  314,  315 

in  injuries  to  palate,  207 

in  lower  lip  injuries,  125,  127,  129,  141,  148, 
150 

in  mouth  injuries,  94 

in  rhinoplasty,  211,  213,  217,  219,  230,  234,  248, 
258 

in  pinna  injuries,  381,  385,  386 

in  upper  lip  injuries,  78-82,  89 

near  the  chin,  22 

oedema  associated  with,  22,  34 

preparation  of  areas  for,  29 

preservation  of  the  life  of,  22 

principles  of,  393 

skin-muscle-mucous  membrane,  148 

suture  and,  32,  33 

transposed,  19 

tubed,  19,  21,  213,  393 

viability  of,  22 
Forceps,  for  suture,  31 

Forehead,  grafting  of  raw  area  on,  after  rhino- 
plasty, method,  18 
Forehead,  skin-graft  on,  297 

Wolfe  graft  to,  273 
Forehead  flaps,  in  chin  injuries,  176 

in  rhinoplasty,  3,  213,  275,  279,  282,  396 
Foreign  bodies,  irritating  tissues,  12 
Fornix,  lower,  loss  of,  335,  338 
Frontal  bone,  injury  to,  with  eyebrow  loss,  304 
Function,  restoration  of,  importance  of,  8 
scar  tissue  impeding,  30 

Glabellar  region,  cartilage  imbedded  over,  271 
flaps  from,  in  rhinoplasty,  214,  215,  217 
prominence  in,  223 

Glass  eye,  skin-covered,  insertion  of,  340,  342 

Grafts.     See  Skin-grafts 

Granulation,  prevention  of,  6 

Hiemorrhage,   during   administration    of    anaes- 
thetics, 27 

into  air-ways,  27,  28 

prevention  of,  during  operation,  29 

secondary,  avoidance  of,  7 
Hair-bearing  flaps,  9,  77-79 

for  lip  injuries,  77 
Hare-lip,  92 

plastic  treatment  of,  392 
Hare-lip  type  of  injury,  106,  123,  124 
Helix,  restoration  of  contour  of,  381 
Hewitt's  air-way,  27,  28 
Hooks,  approximating,  50 
Horsehair  suture,  31,  57 
Hyoscinc  MS  preliminary  hypodermic,  27 
Hypospadias,  393 

Ilium  grafts,  1S8,  189 

to  the  mandible,  178,  179,  180,  188,  189 
Infra-orbital  depression,  311 


Intra-oral  prosthetic  appliances,  201 

Intra-nasal  supports,  vulcanite,  276 

Intra-tracheal  amesthesia,  23 

Invisible  scars,  32 

Iodine,  preparation  of  skin  by,  for  operation,  29 

Japanese  silkworm  gut,  32 
Jaw,  anaesthesia  for  operations  on,  27 
injuries  to,  46,  124,  134 
artificial  pre-maxilla  in,  92 
extensive  loss  in,  70,  71 
new,  depressor  musculature  for,  123,  124 
ramus  of,  ulceration  of  membrane  over,  180 
upper,  loss  of  bony  support  of,  64 

Kahn's  tube  for  administration  of  anaesthetics, 

25,  26 
Keloid  scar  of  upper  lip,  109 

Labiogingival  sulcus,  re-creation  of,  9,  182 

Lachrymation,  344 

Laryngotomy,  26 

Lining  membrane  for  deepened  sulcus,  9 

for  mucous  cavities,  provision  of,  3,  8 

provision  of,  methods  of,  9,  10 
Lip  injuries,  adherence  to  palate  in,  207 

backward  displacement  in,  87 

cheek-flaps  in,  87 

deformity  with  partial  loss  of  nasal  bridge  and 
ala,  240 

dog  bite,  396 

flaps  in,  84,  85 

outer  third  drawn  upwards  and  inwards,  60 

repair  and  replacement  in,  77,  80,  82,  83,  151, 

152,  156,  175 
suture  in,  85,  242 

vermilion  border  in  repair  of,  9,  81,  139,  151, 

153,  156 

cases  illustrating,  138-139 

with  cheek  destruction,  48,  49,  56,  57 
Lip  injuries,  lower,  82,  123-124 

anaesthesia  during  operations  in,  26 

bone  grafting  to  the  mandible  in,  177-180 

cases  illustrating,  125-189 

central  portion,  cases  illustrating,  134-137 

cheek-flap  in,  129,  139,  141 

descending  naso-labial  flaps  in,  142,  150 

diagnosis   dependent  on   accurate    estimation 
of  tissues  lost,  146 

ectropion  in,  125 

lack  of  control  in,  124 

mucous  flaps  in,  152,  156 

naso-labial  flaps  in,  142,  148,  150,  154 

neck-flap  in,  159 

provision  of  new  lip  in,  159,  169,  175 

scar  excision  in,  135-137,  141,  143 

suture  in,  125,  130,  141,  149 
Lip  injuries,  upper,  77—82 

anaesthesia  during  operations  on,  24 

bridge  pedicle  flap  in,  115 

cases  illustrating,  83-119 

chin-flaps  in,  90 

complete  loss  in,  7,  84,  85,  87 

dentures  in,  82,  92,  93 

descending  flaps  in,  97,  103 

ectropion  in,  115 

hair-bearing  flaps  for,  77-79 


INDEX 


405 


Lip  injuries,  Keloid  scar  in,  109 

laceration  and  drooping  in,  support  for,  194 

loss  of  soft  tissue  in,  appliance  for,  195 

mucous  (lap  in,  to  lower  lip,  153 

nasal  flaps  in,  90 

prosthetic  appliance  in,  85,  88 

provision  of  mucous  membrane  in,  81 

repair  in,  columella  in  relation  to,  82 

secondary  corrections  in,  80 

six-flap  operation  in,  89 

suture  in,  93,  97,  101,  103 

total  loss  in,  82,  83 
Lupus,  deformity  of  nose  following,  400 

plastic  treatment  of,  391 
Lymphatic  stasis,  22 

Malar,  cartilage  implant  to,  309 

loss  of,  54,  301 

large  hollow  produced  by,  58 

partial  loss  of,  46 

simulation  of,  16 
Mandible  injuries,  177 

anaesthesia  during  operations  for,  24,  26 

author's  osteochondral  graft  in,  179,  181 

autoflxation  in,  177 

autologous    osteochondral   graft  in,  179,  180, 
181 

Billington's  graft  in,  179,  190 

bone-grafts  in,  anaesthesia  during,  28 

clearly  defined  gaps  in,  6 

complete  destruction  in,  123,  158,  168 

dental  splints  in,  177,  195 

estimation  of  loss,  5 

extensive  loss  in,  70 

fracture,  drainage  of,  6,  7 

grafting  in,  methods,  177-189 

ilium  graft  in,  178,  179,  180 

non-union  in,  179 

osteogenesis  in  grafts  in,  34 

osteoperiosteal  grafts  in,  177,  180 

pedicle  graft  in,  178,  180 

prosthetic  replacement  in,  158 

re-creation  of  labiogingival  sulcus  in,  9,  182 

rib-grafts  in,  177,  179 

summary  of  principles  of  grafting  in,  180 

tibia  grafts  in,  178,  179 

union  in,  70 

Massage,  dispersal  of  oedema  by,  34 
Mastication,  essential  problem  in  palatal  injuries, 

205,  206 
Mastoid  process,  adhesion  of  remnants  of  pinna 

to,  387 

Mattress  sutures  in  cheek  injury,  57 
Maxilla,  anaesthesia  during  operations  on,  24 

artificial,  89 

double  fracture  with  downward  displacement, 
227,  229 

downward  displacement  of,  203 

extensive  loss  of,  cases  illustrating,  197,  198 

falling  in  of  soft  tissues  due  to  extensive  loss, 
197 

forward  rep'acement  of,  195 

fractures  involving  orbital  plate,  203 

loss  of  orbital  plate  of,  301 

prosthetic  appliances  for,  203 

prosthetic  replacement  of,   cases   illustrating, 
196,  198,  199 


Maxilla,  replacement  of,  227,  229 

superior,  loss  of,  62,  64 
cases  illustrating,  64-74 
prosthetic  replacement  of,  196,  198 

See  also  Pre-m  axilla 
Meningocele,  393 

Metallic  plates,  for  building  up  facial  contour,  12 
Methylated  spirit,  preparation  of  skin  for  opera- 
tion by,  29 
Microstoma,  133,  144 

causes  of,  123 

facial  burns,  123 

post-operative,  8 
Moustache,  bridge  pedicle  flap  for,  114 

flaps  providing,  79,  90 
Mouth  injuries,  193 

avoidance  of  secondary  haemorrhage  in,  7 

anaesthesia  during  operations  in,  23 

cavity  lined  by  Thiersch  graft,  200 

contraction  in,  123,  144 

dental  splint  in,  10 

depression  of  corners  in,  77,  90,  91 

destruction  of  corners  in,  62,  130 
cases  illustrating,  130-133 

drainage  from,  6,  7 

drooping  of  muscles  in,  94 

early  treatment  of,  6,  7 

epithelial  inlay  in,  9,  10 

flaps  in,  19,  43,  56,  94 

forcible  replacement  of  palate  in,  71,  72 

operation  to  raise  corners  in,  67 

prosthetic  appliances  in,  193-201 

provision  of  lining  membrane  in,  8 

ring-like  type  of,  144 
Mucosal  grafts,  8 
Mucous  cavities,   provision   of   lining   membrane 

for,  3,  8 

Mucous  flaps,  in  lower  lip  injuries,  152,  156 
Mucous  membrane,  estimation  of  loss  of,  5 

preservation  of  form  and  vitality  of  tags  of,  6 

suture  of,  6 
Mule's  globes,  336 
Muscle  flaps,  for  soft  facial  contour,  14 

in  checking,  52,  55 
Muscle  grafts,  use  of,  14,  16 


Nares,  anterior,  upward  displacement  of,  230 

stenosis  of,  following  imperfect  rhinoplasty,  213 
Nasal  bridge,  autologous  cartilage  graft  to,  293 
cartilage  imbedded  over,  271 
cartilage  support  to,  225 
celluloid  support  to,  226 
depression  or  destruction  of,  201,  222 

cases  illustrating,  223-229 

prosthetic  support  for,  202,  203 
excessive  prominence  of,  398 
loss  of  middle  portions  of,  230 

cases  illustrating,  231-245 
loss  of  upper  half  of,  217 

cases  illustrating,  216,  218-221 
loss  of  upper  quarter  of,  214 

cases  illustrating,  215-216 

treatment,  214 
raising  of,  232 

Nasal  flaps,  in  upper  lip  injuries,  90 
Nasal  reconstruction,  author's  method,  233 


MM; 


INDEX 


Nasal  splint,  with  dental  fixation,  201 

with  extra-oral  fixation,  202 
Nasal  stenosis,  post-operative,  8,  213 

treatment  of.  213 

Nasal  lul>c, administration  of  anaesthetics  by,25, 28 
Naso-labial  flaps,  19 

in  lower  lip  injuries,  121,  142,  148,  130,  154 
Near-far  far-near  suture,  32 
Neck,  liurns  of.  317 

fragments  of  mandible  in,  70 
Neck-flap,  ascending,  19 

for  lower  lip  injury,  159 

Nelalon  method  of  obtaining  cartilage,  13,  14 
Nose,  arrested  development  from  natal  injury,  399 

artificial,  211 

complete  atresia  of,  280 

deformity  following  lupus,  400 

external  covering  of,  213 

hereditary  disease  of,  396,  397 

lining  membrane  of,  211 

syphilitic,  392 

traumatic  deformity  of,  399 
Nose  injuries,  211-214,  217,  222,  230-246,  258 

advancing  flaps  in,  248 

air-way  restored  by  prosthesis,  202 

ala  loss  in,  246 

cases  illustrating,  247-257 

aiuesthcsia  during  operations,  24,  27 

backward  displacement  in,  87 

bone  cartilage  transplant  from  rib  in,  228 

burns,  347 

cartilage  implants  in,  219,  223,  227,  234,  264, 

266,  268,  399 
cases  illustrating,  215-298,  396-400 

clearing  of  air-way  of,  213 

complete    loss    of    bony     and     cartilaginous 
support,  230 

depressed  fractures,  392 

displacement  upwards,  201 

epithelial  lining  in,  221 

establishment  of  air-way  in,  271 

flaps  in,  212,  219,  234,  248,  257,  275,  283,  296 

forehead  flaps  in,  396 

Indian  type  of,  246 
cases  illustrating,  257 

infra-oral  and  extra-oral  appliances  in,  201 

laceration  of  soft  and  hard  tissues,  200 

lateral  displacement,  appliance  for,  201 

loss  of  lower  half,  263,  270 

loss  of  lower  portion  of  nasal  supports,  224 

loss  of  lower  two-thirds,  280,  285 

loss  of  tip  in,  212,  246,  249,  267,  269,  398 
cases  illnsl rating,  247-257 

lower  third,  246 

author's  method  of  treatment,  258 
cases  illustrating,  247-257 

observations  on,  211 

obstructed  air-way  in,  202,  203 

partial  destruction  of  floor  in,  84 

pedicle  Maps  in,  2  13,  245,  257,  261,  275,  283,  2!i(i 

prosthetic  appliances  in,  200-203 

pug-nose  deformity,  211,  230,  231 
cases  illustrating,  232,  237-239 

reconstruction  in,  author's  method,  233 

relaxation  button  in,  220 

replacement  upwards  and  forwards  in,  88 

retention  apparatus  in,  225 


Nose  injuries,  scalp-flaps  in,  236,  239 

skin  lining  for  the  bridge  and  also,  212 

skin  cartilage  Haps  retaining  tip  in  position, 
212,  272 

skin-grafts  in,  246,  295 

sub-total  loss  in,  274 

support  for  lacerated  tissues  in,  201,  203 

surgical  replacement  of  lacerated  tissues  in,  201 

suture  in,  219,  220,  250,  272 

total  loss  in,  259 
except  ala  and  columella,  290 
with  maxillary  and  cheek  loss,  294 

traumatic  deformities,  397-399 

turbinate  grafts  in,  291,  292,  295 

upward  displacement  of  tip,  230 

Vallancey  swing  in,  230,  231 

See  also  Nasal  bridge  ;    Hhinoplasty 

Obturator,  use  of  inferior  turbinate  as,  207 
(Edema,  affecting  skin-flaps,  22 

dispersal  of,  by  massage,  34 
Oil-ether  anaesthesia,  27,  28 
Operations,  stages  of,  29 

technique,  28 

treatment  after,  34 
Optimum  scar,  factors  necessary  for  production 

of,  33 
Orbicularis  palsy,  conditions  due  to,  344 

operation  for,  344 

Orbit,  epithelial-lined  cavity  in,  336 
Orbital  cavity,  epithelialisation  of,  203 
Orbital  plate,  loss  of,  301 

maxilla  fractures  involving,  203 
Orbital  ring,  injuries  of,  301 

cases  illustrating,  302-315 
Oro-nasal  communication,  restoration  of,  206 
Osteochondral  mandible  graft,  180 
Osteoperiosteal  flap  turned  down  from  glabclla, 

215 
Osteoperiosteal    repair    of    fractured    mandible, 

177, 178, 183-185 

Oxygen    and    chloroform    anaesthesia,    methods, 
24-26 

Palate,  deficiency  of,  protection  of  tongue  from 

sutures  in,  204 

forcible  replacement  of,  71,  72 
injuries  to,  205 

anterior  perforations,  16 
classification  of,  206 
dental  aspect  of,  205,  206 
diagnosis  of,  206 
extensive  loss  in,  71 
flaps  in  repair  of,  207 
mastication  during,  205,  206 
method  of  repair,  207 
prosthetic  appliances  in,  205 
recently  sutured,  protection  from  tongue  move- 
ments, 204 

soft  tissues  adhering  to,  206 
I'alpebral  fissure,  closure  of,  344 
Paraffin  wax,  for  building  up  missing  contour,  12 
Paraldehyde,  anaesthesia  by,  28 
Paralysis  of  orbicularis  muscle,  344 
Pedicle,  return  of,  29 

Pedicle  bone-graft,  in  mandible  injuries,  178, 180, 
187-188 


INDEX 


407 


Pedicle  flaps  in  eye  injuries,  309,  358,  362,  365, 369 

in  nose  injuries,  212,  243,  245,  257,  261,  275, 

283,  296,  400 
Petrol  burns,  347 
Pre-maxilla,  destruction  of,  90 

loss  of,  16,  83,  285 

prosthetic  replacement  of,  92,  195,  106 

total  loss  of,  84 
Principles  of  plastic  surgery,  4 
Prosthetic  appliances,  193 

for  loss  of  bone,  200 

in  chin  injuries,  172,  174 

in  eye  injuries,  203-205,  335-337 

in  maxilla  injuries,  196,  198 

in  mouth  injuries,  193-200 

in  nose  injuries,  200-203,  212 

in  palatal  injuries,  205 

in  upper  lip  injuries,  88 

intra-oral  and  extra-oral,  201-203 

object  and  use  of,  193 
Ptosis,  326 
Pug-nose  deformity,  211,  230,  231 

cases  illustrating,  232,  237-239 

standardised  treatment  of,  231 

Radiographic  examination,  necessity  for,  5 
Restoration  of  contour,  12-14,  193-195 
Restoration  of  tissue,  planning  of,  7-10 
Rhinophyma,  392 
Rhinoplasty,  211 

advance  in  the  study  of,  211 

advancing  flaps  in,  214 

anaesthesia  during,  23,  27 

author's  methods,  212,  213 

blepharoplasty  with,  314 

cases  illustrating,  215-298,  396-400 

early  methods  of,  3 

flaps  in,  19,  211,  213 

forehead  flaps  in,  396 

from  the  chest,  212,  213 

grafting  of  raw  area  on  forehead  after,  18 

historical  observations,  3  • 

imperfect,  nasal  stenosis  following,  213 

in  cases  of  lupus,  391 

incisions  for,  274,  281 

Indian  type  of,  291 

lining  membrane  in,  8,  211 

principles  of,  211 

stages  of  the  operation,  29 

supporting  structure  in,  212 

temporal  artery  tube  pedicle  flap  in,  400 

total,  case  illustrating,  259 

turbinate  grafts  and  muco-cartilaginous  flaps 
in,  16 

ulcerative  processes  affecting,  8 

Vallancey  swing  in,  214,  230,  231 

See  alxo  Nose  injuries 
Rib,  ansesthesia  for  operations  on,  27 

bone  cartilage  transplant  from,  228 

cartilage  from,  in  nose  injuries,  231 

in  pinna  injuries,  383 
Rib -grafts,  183-189 

to  the  mandible,  177,  179,  181 

Scalp-flap,  in  chin  injuries,  170 
in  nose  injuries,  236,  239 
in  upper  lip  injuries,  78,  79 


Scars,  cause  of,  6 

depressed,  fat-flaps  for,  14 

due  to  burns,  348 

excision  of,  30 

in  chin  injuries,  164,  167 

in  lip  injuries,  135-137,  141,  143 

following  eye  operations,  321 

function  impeded  by,  30 

in  eye  injuries,  302 

invisible,  32 

of  the  cheek,  37-41 

excision  and  incision  of  diagrams  illustrating, 
61,  63,  65,  69 

optimum,  factors  necessary  for  production  of, 
33 

prevention  of,  6,  28 

Shipway's  warm  ether  apparatus,  27,  28 
Shock,  prevention  of,  during  operation,  29 
Sitting-up  position  during  anaesthesia,  24 
Skin  cartilage  flaps,  in  rhinoplasty,  212,  272 
Skin-flaps.     See  Flaps 
Skin-grafts,  16 

for  burns,  348,  349 

in  building  up  missing  contour,  12 

in  eye  injuries,  314,  315,  332,  344 

in  nose  injuries,  246,  295 

in  pinna  injuries,  383 

indications  for,  16 

preparation  of  areas  for,  29 

thickness  of,  18 

when  preferable  to  flaps,  22 
Skin,  preparation  for  operation,  29 
Speech,  loss  of,  in  jaw  injuries,  124 
Star-shell  burn,  254 
Stent,  holding  Thiersch  graft,  287 

how  held  in  position,  197 
appliance  for,  197 

use  of,  10 

Subcutaneous  fat-flaps,  30 
Sulcus,  deepened,  lining  membrane  for,  9 

dental,  preservation  and  formation  of,  194,  195, 
197 

stent  impression  of,  10 
Supporting  structures,  12 
Suppuration,  early  cutting  of  flaps  predisposing 

to,  6 
Suture,  early  removal  of,  33,  34 

factors  during,  33 

forceps  for,  31 

in  cheek  injuries,  63,  65 

in  chin  injuries,  157-163,  164,  167 

in  eye  injuries,  302,  308,  323 

in  inferior  blepharoplasty,  315 

in  lip  injuries,  84,  242 

in  lower  lip  injuries,  125,  130,  141,  149,  150 

in  nose  injuries,  219,  220,  250,  272 

in  pinna  injuries,  383,  384,  385 

in  upper  lip  injuries,  93,  97,  101,  103 

material  for,  31,  32 

mattress,  in  cheek  injury,  57 

near-far  far-near,  32 

subcuticular,  32 

technique,  31-33 

wire-retention,  from  cheek  to  cheek,  219 
Syphilis,  13 

nasal  supports  in  old  cases  of,  212 
Syphilitic  nose,  plastic  treatment  of,  392 


IUS 


INDEX 


Tagliacozzi  method  of  rhinoplasty,  3 

Tattooing  of  eyelids,  329 

Teeth,  carried  through  the  cheek,  50 

injuries  to,  207 

loose  and  septic,  clearing  of,  6 

loss  of,  193 

preservation  in  good  occlusion,  195 

suspensory  wiring  of  fragments  of,  7 
Temporal  artery  scalp-flap,  78,  400 

for  upper  lip  injuries,  79 
Temporal  llap,  in  eye  injuries,  34,  308 
Temporal  Haps,  in  lip  injuries,  77 
Temporal  muscle  flaps,  74 

in  check  repair,  52,  55 

in  molar  injury,  58 

Tension,  avoidance  of,  on  apposing  sutures,  33 
Tliiersch  grafts,  g 

cases  suitable  for,  16 

in  blepharoplasty,  313 

in  eye  injuries,  336 

in  mouth  wounds,  10 

in  pinna  injuries,  386 

oral  cavity  lined  by,  200 

stent  holding,  287 
Tibia  grafts,  in  nose  injuries,  217 

to  the  mandible,  178,  179,  183-185 
Tissue  fluids,  skin-flaps  and,  22 
Tissue  irritants,  12 
Tissues,  damaged,  replacement  in  normal  position, 

6 
undue  stretching  of,  6 

estimation  of  distortion  of,  5 

estimation  of  loss  of,  5 

hard,  displaced  fragments  of,  194 

materials  and  appliances  irritating,  12 


Tissues,  normal,  early  replacement  of,  5 

replacement  of,  12,  193 

restoration  of,  planning  of,  8 

See  also  Bony  tissue 
Tongue,  protection  from  sutures  in  operations  on 

palate,  204 

Trachea,  blood  entering,  27 
Tracheotomy,  26 
Transposed  flaps,  19-20 
Treatment,  early,  5 

principles  of,  5-7 

indifferent,  causes  of,  4 
Tripier  operation,  59 

Tube  pedicle  rhinoplasty  from  chest,  213 
Tubing  of  skin-flaps,  19,  21,  213,  393 
Turbinate,  inferior,  in  palatal  injuries,  207 

inferior,  use  as  partial  or  complete  obturator, 

207 
Turbinate  grafts,  291,  292,  295 

Ulcerative  processes,  following  rhinoplasty,  8 
Ulcers,  plastic  treatment  of,  393 
Urethra,  stricture  of,  393 

Vallancey  swing,  in  rhinoplasty,  214,  230,  231 
Venous  stasis,  22 
Vulcanite  nasal  support,  276 
Vulcanite  plates,  building  up  of  missing  contour 
with,  12 

Wax,  in  building  up  of  missing  contour,  12 
Wolfe  graft,  16 

in  ala  injuries,  247 

to  forehead,  273 

relieving  ectropion,  366 


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